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HUGHES' 
COMPEND   OF   PRACTICE 


SIXTH  PHYSICIANS'   EDITION. 


BASED  ON   RECENT  MEDICAL  LITERATU RE 

Gould's  Medical  Dictionaries 

BY  GEORGE  M.  GOULD,  A.M.,  M.D. 

Editor  "  American  Medicine  "  ;  President,  1893-94,  American  Academy  of  Medicine 

The  Illustrated  Dictionary  of  Medicine, 
Biology,  and  Allied  Sciences 

Including  the  Pronunciation,  Accentuation,  Derivation,  and  Definition  of  the  Terms  Used 
in  Medicine  and  those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistry,  Pharmacology,  Microscopy,  etc.  With  many  I'seful  Tables  and 
numerous  Fine  Illustrations.  Large,  Square  Octavo.  1633  pages.  Fifth  Edition,  now 
ready. 

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Including  all  the  Words  and  Phrases  generally  used  in  Medicine,  with  their  Proper  Pro- 
nunciation and  Definition,  Based  on  Recent  Medital  Literature.  With  Tables  of  the 
Bacilli,  Micrococci,  Leukomains,  Ptomains,  etc.,  of  the  Arteries,  Muscles,  Nerves, 
Ganglia,  and  Plexuses  ;  Mineral  Springs  of  the  U.  S.,  etc.,  and  a  very  complete  table 
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nietric  Scales,  and  a  Dose-list  of  Drugs  and  their  Preparations,  in  both  the  English 
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COMPEND 


PRACTICE   OF  MEDICINE 


BY 

DAN'L  E.  HUGHES,  M.D., 

CHIEF   RESIDENT   PHYSICIAN',  PHILADELPHIA   HOSPITAL;    PHYSICIAN-IN-CHIEF,    INSANE 

DEPARTMENT,   PHILADELPHIA   HOSPITAL;    LATE  DEMONSTRATOR    OF 

CLINICAL    MEDICINE    IN    THE    JEFFERSON    MEDICAL 

COLLEGE  OF   PHILADELPHIA,    ETC.,    ETC. 


SIXTH  PHYSICIANS'  EDITION. 


THOROUGHLY  REVISED  AND  ENLARGED. 


INCLUDING  A  SECTION   ON   MENTAL  DISEASES  AND  A  VERY  COM- 
PLETE SECTION  ON  SKIN  DISEASES. 


PHILADELPHIA  : 

P.    BLAKISTON'S    SON    &    CO., 

IOI2     WALNUT     STREET. 

1903 


Copyright,  1899,  by  P.  Klakiston's  Son  &  Co. 


WM.   F.    FELL   &   CO., 

rLECTROTYPERS     AND    PRINTERS, 

I230-24    SANSOM    STREET, 

PHILADELPHIA. 


en 


Q. 


TO 
HIS  ESTEEMED  FRIEND  AND  TEACHER, 

3".  ^.  ®a  Costa,  /llb.2)., 

PROFESSOR  OF  THE  PRACTICE  OF  MEDICINE   IN  THE 
JEFFERSON    MEDICAL  COLLEGE, 

THIS   COMPEND 

IS  RESPECTFULLY  DEDICATED  BY 

THE  AUTHOR. 


PREFACE  TO  SIXTH  EDITION. 


The  continued  demand  for  the  Compend  of  Medicine  has  en- 
couraged the  author  to  make  its  sixth  edition  the  most  complete 
of  any  similar  book.  It  was  never  intended  that  the  Compend 
should  in  any  way  replace  the  text-books  upon  the  practice  of 
medicine,  but,  on  the  contrary,  it  was  written  to  be  an  aid  to  the 
medical  student,  at  a  time  when  practical  demonstrations  and  ward 
classes  were  the  exception  in  the  college  curriculum.  The  book 
has,  however,  somewhat  outgrown  the  original  plan,  and  having 
met  with  considerable  favor  from  physicians,  the  author  has  en- 
deavored to  make  it  more  useful  to  the  profession  without  changing 
the  arrangement  which  has  made  it  so  popular  with  the  student, 
always  keeping  in  mind,  however,  that  it  is  a  compend  and  not  a 
treatise  on  medicine.  The  addition  of  the  section  on  Mental 
Diseases  has  been  kindly  received,  and  has  justified  the  statement 
in  the  preface  to  the  fifth  edition  that  no  medical  student's  education 
should  be  considered  as  completed  without  some  knowledge  of 
insanity,  the  increase  of  which  is  the  alarm  of  the  closing  hours  of 
the  century. 

D.  E.  H. 


CONTENTS. 


PAGE 

INTRODUCTION 9 

FEVERS, 15 

General  Treatment  of  Fevers, 16 

Continued  Fevers, 17 

Periodical  Fevers, 39 

Eruptive  Fevers, , 51 

DISEASES  OF  THE  MOUTH,     68 

DISEASES  OF  THE  STOMACH 76 

DISEASES  OF  THE  INTESTINAL  CANAL, 99 

INTESTINAL  PARASITES, 134 

DISEASES  OF  THE  PERITONEUM, 140 

DISEASES  OF  THE  BILIARY  PASSAGES 147 

DISEASES  OF  THE  LIVER 151 

DISEASES  OF  THE  KIDNEYS , 159 

DISEASES  OF  THE  BLOOD 195 

ACUTE  GENERAL  DISEASES 209 

DISEASES  OF  THE  RESPIRATORY  SYSTEM, 244 

DISEASES  OF  THE  NASAL  PASSAGES, 263 

DISEASES  OF  THE  PHARYNX, 269 

DISEASES  OF  THE  LARYNX 274 

DISEASES  OF  THE  BRONCHIAL  TUBES 290 

DISEASES  OF  THE  LUNGS 316 

DISEASES  OF  THE  PLEURA, 346 

DISEASES  OF  THE  CIRCULATORY  SYSTEM, 352 

DISEASES  OF  THE  NERVOUS  SYSTEM, 401 

vii 


viii  CONTENTS. 

PACK 

DISEASES  OF  THE  CEREBRAL  MEMBRANES 402 

DISEASES  OF  THE  CEREBRUM 409 

DISEASES  OF  THE  SPINAL  CORD, 449 

DISEASES  OF  THE  NERVES 475 

GENERAL  OR  NUTRITIONAL  DISEASES 484 

MENTAL  DISEASES 504 

DISEASES  OF  THE  SKIN 53i 

INDEX 611 


COMPEND 


PRACTICE  OF  MEDICINE. 


INTRODUCTION. 

The  Principles  of  Medicine  constitute  what  may  be  termed 
Medical  Science. 

The  Practice  of  Medicine  is  the  exercise  of  medical  art,  and 
embraces  all  that  pertains  to  the  knowledge  of,  prevention,  and  cure 
of  the  diseases  which  the  physician  is  called  upon  to  treat. 

Disease  may  be  defined  as  any  departure  from  the  normal  stand- 
ard of  structure  or  function  of  an  organ  or  tissue  or  in  both  com- 
bined :  Organic  disease,  when  associated  with  an  organic  change  in 
the  affected  part ;  Functional  disease ,  when  the  abnormal  phenomena 
are  independent  of  any  discoverable  structural  lesion.  It  is  question- 
able whether  alterations  of  function  can  occur  without  alteration  in 
structure. 

The  study  of  disease,  whether  organic  or  functional  in  character, 
is  termed  Pathology. 

Pathology  is  the  science  that  treats  of  disease  in  all  its  aspects, 
and  explains  the  origin,  causes,  clinical  history,  and  nature  of  the 
various  morbid  conditions  which  may  disturb  the  economy. 

The   study   of  individual  diseases  constitutes   Special  Pathology, 

9 


10  PRACTICE    OF    MEDICINE. 

while  llie  study  of  the  morbid  conditions  common  to  a  greater  or  less 
number  of  diseases  constitutes  General  Pathology. 

Nomenclature,  or  the  naming  of  diseases,  is  a  subdivision  of  gen- 
eral pathology.  The  real  value  of  nomenclature  applied  to  disease  is 
that  the  name  chosen  shall  express  the  morbid  condition  involved, 
and,  if  possible,  its  location. 

If  the  morbid  condition  be  an  inflammation,  the  suffix  itis  is  added 
to  the  anatomical  name  of  the  part  affected ;  thus,  if  the  disease  be 
an  inflammation  of  the  peritoneum,  it  is  \.&xrc\td  peritonitis. 

If  the  morbid  condition  be  catarrhal,  such  as  a  transudation  or 
flux,  the  liquid  escaping  upon  a  mucous  surface,  the  suffix  rha'a  is 
used  ;  thus,  a  catarrhal  inflammation  of  the  intestinal  tract  is  termed 
diarrhoea  and  enterorrhcea. 

If  the  morbid  condition  be  a  flow  of  blood  or  a  hemorrhage  from  a 
mucous  surface,  the  suffix  rhagia  is  used  ;  thus,  a  hemorrhage  from 
the  small  intestines  is  termed  enterorrhagia. 

If  the  morbid  condition  be  pain  without  inflammation,  the  suffix 
algia  is  used.  The  various  forms  of  neuralgias  are  examples  ;  for 
instance,  neuralgia  of  the  stomach  is  termed  gastralgia. 

If  the  morbid  condition  be  in  the  blood,  the  suffix  (pmia  is  used. 
Thus,  Anceviia  is  impoverishment  of  the  blood  ;  Urcetnia,  the  morbid 
accumulation  of  urea  in  the  blood ;  Septicemia,  putrid  infection  of 
the  blood  ;  Pycemia,  purulent  infection  of  the  blood. 

If  the  morbid  condition  be  in  the  urine,  the  ending  uria  is  used. 
Albuminuria,  when  albumin  in  the  urine  ;  Hcematuria,  when  blood 
in  the  urine ;   Oxaluria,  when  oxalates  occur  in  the  urine. 

If  the  morbid  condition  be  a  dropsical  affection,  the  prefix  hydro  is 
added  to  the  part  affected.  A  dropsical  accumulation  in  the  perito- 
neum is  termed  hydro  peritoneum. 

If  the  morbid  condition  be  that  of  air  in  an  unnatural  part,  the 
prefix  pneuvio  to  the  name  of  the  part  is  used,  as  in  pneutno  thorax. 

If  the  morbid  condition  be  an  inflammation  of  the  membrane 
investing  the  part  inflamed,  the  prefix  peri  is  used.  Thus,  an  inflam- 
mation of  the  investing  membrane  of  the  kidney  is  termed  perine- 
phritis. 

Inflammation  of  the  connective  tissue  surrounding  an  organ  is 
designated  by  the  prefix /ara.  Thus,  parametritis  for  inflammation 
of  the  connective  tissue  about  the  womb. 

A  termination  in  oma  signifies  a  tumor,  as  in  sarcoma  or  carcinoma. 


INTRODUCTION.  11 

The  su^x  pathy  is  used  to  designate  a  morbid  condition  of  a  part, 
without  indicating  its  particular  character,  an  example  being  the  use 
of  the  term  e7icephalopathy. 

Morbid  Anatomy,  or  pathological  anatomy,  a  subdivision  of 
pathology,  is  the  study  of  the  changes  in  the  tissues  and  fluids  of  the 
body  after  death,  appreciable  either  to  the  naked  eye  or  with  the  aid 
of  the  microscope. 

Bacteriology  is  that  division  of  science  concerned  with  the  study 
of  bacteria,  an  important  and  developing  etiological  factor  in  the 
field  of  medicine  and  surgery. 

Histology  is  the  study  of  the  minute  anatomy  of  the  tissues  and 
fluids  of  the  body  with  the  microscope  and  clinical  chemistry. 

Haematology,  or  the  science  of  the  blood,  its  nature,  functions, 
and  disorders. 

Pathogenesis  is  the  study  of  the  origin  and  development  of 
pathological  processes  or  disease. 

Lesions  {Icedo,  to  hurt)  are  appreciable  anatomical  changes. 

Etiology  is  that  subdivision  of  general  pathology  which  treats 
of  the  causes  of  disease.  The  knowledge  of  the  cause  of  any  mor- 
bid action  is  of  value  in  the  prevention, management,  and  removal  of 
disease. 

The  Causes  of  disease  may  be  divided  into  internal,  external, 
ordinary,  specific,  primary,  secondary , predisposing-,  and  exciting. 

Examples  of  internal  or  intrinsic  causes  are  those  having  their 
origin  in  the  mind,  such  as  prolonged  mental  application,  intense  or 
long-continued  emotional  excitement,  long-continued  mental  depres- 
sion, and  the  possession  of  and  concentration  upon  a  predominant 
idea.  Other  examples  are  the  accumulation  of  certain  products  in 
the  blood,  such  as  urea,  uric  acid,  or  lactic  acid,  or  the  absorption  of 
ptomaines  from  the  gastric  or  intestinal  tract. 

External  or  extrinsic  causes  are  such  as  infectious  miasms,  viruses, 
poisons,  wounds,  and  injuries. 

An  ordinary  cause  is  one  to  which  all  are  more  or  less  exposed, 
such  as  atmospheric  changes. 

Specific  or  special  causes  are  those  producing  a  distinct  and  specific 
disease,  such '  as  the  bacillus  tuberculosis,  causing  Tuberculosis ; 
comma  bacillus,  Asiatic  Cholera  ;  oscillaria  malarice,  Malaria  ;  Loffier 
bacillus,  Diphtheria. 

A  contagious  disease  is  one  whose  causative  agent  is  a  specific 


12  PRACTICE    OF    MEDICINE. 

poison  that,  introduced  into  the  system  of  another,  will  give  rise  to 
the  same  disease.  An  infectious  disease  is  also  due  to  a  special  cause 
that  under  certain  conditions  is  capable  of  unlimited  increase  or  mul- 
tiplication.    An  infectious  disease  may  or  may  not  be  contagious. 

An  example  of  a  primary  cause  is  any  external  traumatic  injury. 

A  secondary  cause  is  well  seen  in  the  secondary  pericarditis  result- 
ing from  an  accumulation  of  urea  in  the  blood,  the  retention  of  the 
urea  in  the  blood  being  due  to  a  diseased  kidney. 

A  predisposition  to  disease  is  a  special  liability  or  susceptibility  to 
its  occurrence,  and  may  be  either  inherited  or  acquired. 

Inherited  ox  constitutional  predisposition  to  certain  diseases  is  also 
termed  Diathesis  ;  an  example  is  the  offspring  of  phthisical  parents, 
who  are  said  to  be  of  71  phthisical  diathesis. 

Acquired  predisposition  is  such  as  arises  from — 
I.    Habits:  Strain  upon  the  nervous  system  resulting  in  nervous 
diseases,  or  the  changes  resulting  from  alcoholic  or  other 
excesses. 

II.  Age:   Children  are  very  liable  to  catarrhal  disorders.     Young 

adults,  to  fevers  and  perverted  sexual  disorders. 
Middle  age,  to  heart,  kidney,  and  digestive  disorders,  and 

cancer. 
Old  age,  to  degeneration  of  the  heart  and  vessels, 

III.  Occupation:   Miners,  weavers,  and  cutlers,  lung  diseases;  or 

painters  and  printers,  to  lead  colic. 

IV.  Sex  :  Women,  emotional  nervous  diseases. 

Men,  as  more  exposed,  rheumatism  and  pneumonia. 
V.    Race  :  Negro,  phthisis  and  scrofula  ;  often  exempt  from  mal- 
aria. 
Exciting  causes  are  those  giving  rise  to  morbid  conditions  in  indi- 
viduals already  predisposed  to  certain  diseases,  but  lacking  the  action 
which  determines  their  occurrence,  to  wit :  persons  predisposed  to 
acute  rheumatism,  on  being  exposed  to  certain  atmospheric  changes 
have   an    attack ;    fear  has    produced    chorea ;    anger   has   caused 
jaundice  ;  worry  has  produced  cardiac  and  mental  diseases. 

The  Clinical  History  of  diseases  includes  all  the  symptoms  and 
signs  which  may  occur  from  the  period  of  incubation  until  its  final 
termination. 

Symptomatolog'y  is  the  study  of  the  signs  and  symptoms  of 
disease  or  such  alterations  in  the  healthy  functions  giving  evidence  of 


INTRODUCTION.  13 

the  existence  of  a  diseased  condition  or  perverted  function.  Symp- 
toms may  be  either  objective  or  subjective  :  Objective,  when  evident 
to  the  senses  of  the  observer,  as  redness,  swelling,  high  temperature, 
or  disorders  of  locomotion ;  Subjective,  when  felt  or  known  only  by 
the  patient,  such  as  pain,  numbness,  vertigo,  or  nausea. 

Physical  signs  are,  strictly  speaking,  objective  symptoms,  requir- 
ing for  their  elucidation  special  methods,  such  as  inspectiojt,  mensura- 
tion, palpation,  percussion,  and  auscultation.  These  methods  are 
chiefly  used  in  examinations  of  the  chest  and  abdomen. 

Associated  with  the  study  of  symptomatology  should  be  considered 
the  complications  and  sequelce  of  disease. 

Complications  are  certain  conditions  which  may  arise  during  the 
course  of  the  original  disease,  but  are  not  considered  necessary 
accompaniments  of  the  disease;  thus  hemorrhage  from  the  lungs  or 
haemoptysis  is  a  complication  of  tuberculosis  ;  intestinal  hemorrhage, 
a  frequent  complication  of  typhoid  fever. 

SequelcB  {sequor,  I  follow)  are  the  morbid  phenomena  left  as  a 
result  of  a  disease ;  thus,  valvular  disease  of  the  heart  often  results 
from  an  attack  of  acute  articular  rheumatism. 

The  Period  of  Incubation  is  that  interval  between  the  en- 
trance of  a  poison  ,into  the  system  and  the  manifestation  of  its 
symptoms. 

The  Prodromes  are  the  earliest  recognizable  symptoms ;  as  the 
rigors  or  chills  during  the  invasion  of  fever,  and  the  various  auras 
preceding  an  epileptic  attack. 

An  acute  disease  is  one  in  which  the  invasion  is  sudden  and  rapid, 
and  as  a  rule  severe ;  when  the  symptoms  develop  less  rapidly  and 
are  less  intense,  the  disease  is  said  to  be  subacute ;  when  gradual 
or  slow  in  development,  duration,  and  intensity,  the  disease  is  said 
to  be  chronic.  It  must  be  borne  in  mind,  however,  that  there 
may  be  disturbed  action  in  every  intermediate  degree  between  these 
extremes. 

Pathognomonic  is  the  term  applied  to  such  symptoms  as  belong 
to  one  particular  disease,  and  are  therefore  characteristic  of  it,  thus : 
the  rusty  sputum  of  pneumonia,  or  the  eruption  of  variola. 

The  Termination  of  a  diseased  action  may  occur  in  one  of  three 
ways,  to  wit :   Cure,  Secondary  Processes,  or  in  Death, 

Cure  may  occur  by — 

Lysis,  or  slow  return  to  health.     Crisis,  abrupt  termination,  usually 


14  PRACTICE    OF    MEDICINE. 

with  a  critical  discjiarge.  Metastasis,  or  changing  from  one  location 
to  another. 

Secondary  Processes  are  those  in  which  the  diseased  action  is  sub- 
stituted by  a  new  morbid  process,  to  wit :  rheumatism  followed  by 
endocarditis  ;  apoplexy  by  cerebral  softening. 

By  Death  is  meant  a  complete  cessation  of  tissue  change  occurring 
by- 

Asthenia,  or  an  ever-increasing  debility,  to  wit:  phthisis,  cancer, 
Bright's  disease.  Ancemia,  or  insufficient  quantity  or  quality  of 
blood.  Apncca,  or  non-aeration  of  blood,  to  wit :  acute  lung  dis- 
eases, or  croup.  Coma,  death  beginning  at  the  brain,  to  wit:  urae- 
mia, narcotic  poisoning,  or  cerebral  hemorrhage. 

Diagnosis  of  disease,  or  the  discrimination  of  diseases,  implies  a 
complete,  exact,  and  comprehensive  knowledge  of  the  phenomena 
under  consideration,  as  regards  the  origin,  seat,  extent,  and  nature  of 
all  its  morbid  condition. 

A  direct  diagnosis  is  made  when  the  morbid  condition  is  revealed 
by  a  combination  of  clinical  phenomena,  or  some  one  or  more  pathog- 
nomonic symptoms. 

A  differential  diagnosis  is  the  result  when  the  diseases  resembling 
each  other  are  called  to  mind  and  eliminated  from  each  other. 

A  diagnosis  by  exclusion  is  by  proving  the  absence  of  all  diseases 
which  might  give  rise  to  the  symptoms  observed,  except  one,  the 
presence  of  which  is  not  actually  indicated  by  any  positive  symptoms. 

The  X-  (or  Rontgen)  Rays,  now  in  its  infancy  in  diagnosis,  will  in 
the  near  future  revolutionize  the  study  of  diseases  of  internal  organs 
and  structures. 

Prognosis  of  disease  is  the  ability  or  knowledge  to  foretell  the 
most  probable  result  of  the  condition  present,  and  involves  an  amount 
of  tact  or  knowledge  only  acquired  by  prolonged  clinical  experience. 

Treatment.  The  ultimate  and  most  important  object  in  the 
study  of  medicine,  from  a  practical  point  of  view,  is  to  be  able  to  cure, 
relieve,  or  prevent  disease.  This  does  not  consist  solely  in  the  ad- 
ministration of  drugs,  but  requires  strict  and  faithful  attention  to  diet, 
hygiene,  and  exercise. 

When  the  object  is  to  prevent  disease,  such  as  small-pox  by  vacci- 
nation, it  is  called  Prophylactic  or  Preventive  treatment. 

When  disease  is  to  be  broken  up,  although  already  begun,  such  as 
aborting  the  chill  of  malaria,  it  is  called  the  Abortive  treatment. 


FEVERS.  15 

When  the  disease  is  allowed  to  run  its  natural  course  without 
attempting  its  removal,  but  being  constantly  on  the  alert  for  obstacles 
to  its  successful  issue,  such  as  the  generally  adopted  plan  of  treating 
continued  fevers,  it  is  called  Expectant  treatment. 

When  the  disease  is  incurable,  and  removal  of  marked  suffering  is 
the  object,  it  is  called  Palliative  treatment. 

When  marked  weakness  and  prostration  are  to  be  overcome,  it  is 
called  Restorative  treatment. 


FEVERS. 


Fever  is  a  condition  in  which  the  temperature  of  the  human  body 
is  raised  above  .the  normal  limit, — 98.2°  F., — and  there  are  present 
the  phenomena  of  quickened  circulation,  marked  tissue  change,  and 
disordered  secretions.^ 

^'Wq  primary  cause  of  the  fever  phenomena  is  still  a  mooted  ques- 
tion, and  is  either  a  disorder  of  the  sympathetic  nervous  system  giv- 
ing rise  to  disturbances  of  the  vaso-motor  filaments,  or  a  derangement 
of  the  nervous  centres  located  adjacent  to  the  corpus  striatum,  which 
have  been  found,  by  experiment,  to  govern  the  processes  of  heat  pro- 
duction, distribution,  and  dissipation,  or  a  toxsemia, — viz.  :  ptomaines, 
uraemia,  or  other  poisons, — or  of  a  bacterial  origin. 

Rise  of  temperature  is  the  preeminent  feature  of  all  fevers,  and  can 
only  be  positively  determined  by  the  use  of  the  clinical  thermometer, 
TJie  i&rmfeverishness  is  used  when  the  temperature  ranges  from  99°  to 
100°  F. ;  slight  fever  if  100°  or  101°;  moderate,  102°  or  103°;  high 
if  104°  or  105°  ;  and  intense  if  it  exceed  the  latter.  The  term  hyper- 
pyrexia is  used  when  the  temperature  shows  a  tendency  to  remain  at 
106°  F.  and  above. 

Quickened  circulation  is  the  rule  in  fevers,  the  frequency  usually 
maintaining  a  fair  ratio  with  the  increase  of  the  temperature.  A  rise 
of  one  degree  Fahrenheit  is  usually  attended  with  an  increase  of 
eight  to  ten  beats  of  the  pulse  per  minute. 


Ifi  PRACTICE   OF    MEDICINE. 

The  following  table  gives  a  fair  comparison  between  temperature 
and  pulse  : 

A  temperature  of     98°  F.  corresponds  to  a  pulse  of    60 

"  '«  100°  F.  "  "  "  80 

<«  "  101°  F.  "  "  "  90 

i<  <<  102°  F.  •'  "  "  icx> 

"  "  103°  F.  "  "  "  no 

«'  •*  104°  F.  "  "  "  120 

<<  "  105°  F.  "  "  "  130 

"  "  106°  F.  "  "  "  140 

TAe  tissue  waste  is  marked  in  proportion  to  the  severity  and  dura- 
tion of  the  febrile  phenomena,  being  slight  or  nil  in  febricula,  and 
excessive  in  typhoid  fever. 

The  disordered  secretions  are  manifested  by  the  deficiency  in  the 
salivary,  gastric,  intestinal,  and  nephritic  secretions,  the  tongue  being 
furred,  the  mouth  clammy,  and  there  occurring  anorexia,  thirst,  con- 
stipation, and  scanty,  high-colored,  acid  urine. 


GENERAL  TREATMENT  OF  FEVERS. 

1.  Reduce  the  temperature.  The  cold  bath  or  cold  pack  will  do 
this  most  decidedly,  but  entails  much  labor,  and  is  not  altogether  free 
from  danger,  and  so  its  use  is  advised  only  in  proper  cases.  Cool 
sponging  is  of  decided  value.  Quinines  sulphas,  in  gr.  xx  (1.3  Gm.) 
doses,  repeated,  rarely  fails.  Antipyrin,  gr.  xx  (r.3  Gm.),  repeated, 
antifebrin,  gr.  x-xv  (0.65-1.0  Gm.),  repeated,  and  phenacetin,  gr,  v 
(0.32  Gm.),  repeated  once  or  twice,  are  also  recommended,  but  their 
tendency  to  depression  must  be  watched. 

2.  Lessen  the  circulation.  If  the  pulse  be  full,  strong,  and  rapid, 
use  aconitum  or  verairuvi  viride.  If  the  circulation  be  weak,  stimu- 
lants with  digitalis,  caffeina,  and  nitroglycerin  are  indicated. 

3.  Attend  to  the  secretions.  Remove  the  waste  of  the  tissues  by 
diuretics,  diaphoretics,  and,  if  particularly  indicated,  laxatives.  It  is 
better  for  every  fever  that  the  skin  should  be  moist,  than  that  it  should 
be  harsh  and  dry.  It  is  better  that  the  urine  should  be  abundant, 
than  that  it  should  be  scanty  and  thick  with  tissue  waste.  Watch  the 
stools  that  you  may  judge  whether  the  food,  be  it  solid  or  liquid,  is 


FEVERS.  17 

properly  digested.     The  free  use  of  water  is  beneficial  in  promoting 
the  various  secretions. 

4.  Nourish  the  patient.  "  Don't  starve  a  fever."  Administer  milk, 
beef-tea,  animal  broths,  peptonized  and  other  light  nutritious  food,  in 
small  quantities,  but  at  frequent  intervals,  watching  that  tympanites 
does  not  develop. 

Alcohol  is  only  indicated  in  long-continued  fevers  or  those  of 
asthenic  type.  Check  or  discontinue  alcohol  when  its  odor  is  notice- 
able on  the  breath, 

5.  Watch  the  nursing.  Much  of  the  success  in  the  management 
of  fever  patients  can  be  attributed  to  good,  sensible  nursing.  Through 
it  are  secured  the  five  important  essentials  of  every  sick-room  ;  to 
wit :  cleanliness,  cheerfulness,  regularity,  ventilation,  and  light. 


CONTINUED  FEVERS. 

All  continued  fevers  are  characterized  by  a  steady  progress  of  the 
febrile  movement,  without  either  a  too  decided  rise  or  fall  in  the  tem- 
perature to  modify  the  impression  of  a  continuous  action. 


SIMPLE  CONTINUED  FEVER. 

Synonyms.  Irritative  fever  ;  febricula ;  ephemeral  fever ;  synocha. 

Definition.  A  continued  fever,  of  short  duration,  mild  in  charac- 
ter, rarely  fatal,  but  when  death  does  occur,  presenting  no  character- 
istic lesion. 

Causes.  Fatigue,  mental  and  physical ;  exposure  to  the  sun ; 
great  heat  or  cold ;  excesses  in  eating  and  drinking  resulting  in  an 
attack  of  indigestion  ;  excitementand  violent  emotion.  Most  common 
in  childhood.     It  is  not  a  miasmatic  fever,  neither  is  it  contagious. 

Symptoms.  Onset  sudden  with  an  abrupt  feeling  of  lassitude, 
followed  by  a  decided  chill  or  chilliftess,  a  sudden  and  rapid  rise  of 
temperattire ,  quick,  tense  pulse,  headache,  dry  skin,  great  thirst,  coated 
tongue,  costive  bowels,  and  scanty,  high-colored  urine.  Cases  due  to 
errors  in  diet  are  accompanied  by  tiatisea  and  vomiting.  Attacks 
occurring  during  childhood,  due  to  excitement,  fright,  or  the  emotions, 
may  be  associated  with  convulsions.  The  temperature  may  within  an 
2 


18  PRACTICE    OF    MEDICINE. 

hour  or  two  reach  103°  F.,  or  more,  when  slight  delirium  may  occur. 
The  affection  has  no  constant  or  characteristic  eruption. 

Duration.     From  twenty-four  hours  to  six  or  seven  days. 

Termination.  Usually  within  a  few  hours,  to  a  day  or  two,  the 
temperature  rapidly  falls  to  the  norm,  an  instance  of  crisis  ;  or  it  may 
continue  for  several  days,  gradually  falling  to  the  norm  {/ysis).  Herpes 
about  the  lips  and  nostrils  are  often  observed  at  the  close  of  an  attack. 
Coti7>alcscence  is  rapid. 

Diagnosis.  Unless  the  fever  can  be  attributed  to  some  one  of 
the  causes  mentioned,  a  doubt  as  to  its  character  may  exist  for  the 
first  twenty-four  hours,  after  which  time  it  can  hardly  be  mistaken  for 
any  other  disease. 

The  following  is  a  familiar  instance  of  this  affection.  A  child,  apparently 
in  the  best  of  healtli,  at  play,  or,  may  be,  at  school,  suddenly  complains  of 
nausea  and  may  vomit,  the  skin  becoming  hot,  dry,  and  flushed,  or  soon  cov- 
ered with  an  erythematous  rash  ;  the  pulse  is  quick  and  tense,  there  is  head- 
ache, pains  in  the  limbs,  and  great  fretfulness  or  nervousness.  The  axillary 
temperature  may  reach  I02°-I04°  F.  The  whole  aspect  is  most  alarming. 
A  laxative  is  administered,  the  surface  sponged  with  a  tepid  lotion,  sleep 
follows,  during  which  there  may  be  free  perspiration,  and  the  following  day 
the  child  is  and  continues  perfectly  well. 

Pl'Ognosis.     Recovery,  without  sequelae,  the  rule. 

Treatment.  Rest  in  bed.  If  evidences  of  gastro-intestinal  dis- 
order be  present,  order  a  dozen  or  more  powders  containing  hydrar- 
gyri  chloridimite,  gr.  Y^  (o.oi  Gm.);  sodii  bicarbon.,  gr.  ij  (0.13  Gm.), 
pulv.  ipecac,  gr.  -^  (0.005  Gm.),  one  every  two  hours,  and  some 
hours  after  the  last  powder  has  been  taken,  an  enema  or  a  seidliiz 
powder.  Much  comfort  follows  spottging-  the  surface  with  tepid  or 
cold  water  and  the  use  of  saline  diaphoretics  and  diuretics.  If  the 
pulse  be  very  quick,  add  small  doses  of  aconilum.  Cases  not 
associated  with  digestive  disorder  have  the  fever  and  nervous 
symptoms  relieved  by  acetanilidum,  gr.  ij-v  (0.13-0.32  Gm.),  accord- 
ing to  age,  every  two  or  three  hours.  Liquid  diet  is  the  most  palatable. 
Cases  in  which  the  nervous  symptoms  or  insomnia  are  prominent 
should  have  a  few  doses  of  potassii  broniidum  during  the  day,  or  a 
bedtime  dose  of  irional,  gr.  v-xx  (0.32-1.3  Gm.).  During  convales- 
cence tonic  doses  of  quinines  sulphas  or  tinctura  nucis  vomicce. 


FEVERS.  19 

INFLUENZA. 

Synonyms.  La  grippe ;  grip  ;  contagious  catarrh  ;  epidemic  or 
catarrhal  fever. 

Definition.  An  acute,  specific,  infectious  fever,  moderately  con- 
tagious ;  sporadic,  epidemic,  and  pandemic  ;  associated  with  catarrhal 
inflammation  of  the  respiratory  tract,  sometimes  of  the  digestive, 
muscular  pain,  and  always  accompanied  with  disturbances  of  the 
nervous  system  and  a  debility  out  of  all  proportion  to  the  intensity  of 
the  fever  and  the  catarrhal  processes  and  apt  to  be  attended  with 
serious  complications  and  sequelae. 

The  disease  was  almost  unknown  upon  the  appearance  of  the 
pandemic  in  the  winter  of  1889-90. 

Causes.  A  specific  poison,  the  bacillus  of  Pfeiffer,  which  is  unin- 
fluenced by  soil,  climate,  season,  or  atmospheric  changes.  The  mode 
of  development  of  the  remarkable  outbreaks  of  influenza  is  not  yet 
understood.     One  attack  rather  predisposes  to  another  attack. 

Morbid  Anatomy,  There  are  no  characteristic  anatomical 
lesions.     Any  anatomical  changes  are  those  of  the  complications. 

Symptoms.  The  clinical  history  of  this  disease  presents  the 
greatest  variations  as  regards  intensity,  from  the  most  trifling  indis- 
position in  one,  to  an  illness  of  the  gravest  kind,  terminating  in  death, 
in  another. 

The  onset  is,  in  the  majority  of  cases,  sudden,  with  a  chill  or  chilli- 
ness followed  hy  fever,  the  temperature  reaching  101°  to  103°,  a  quick, 
compressible  pulse,  and  severe  shooting  pains  in  the  eyes  and  frontal 
sinuses  and  myalgic  pains  in  the  joints  and  muscles.  The  chill  and 
fever  are  rapidly  followed  by  chilliness  along  the  spifie,  pain  in  the 
throat,  hoarseness,  deafiess,  coryza,  sneezing,  injected,  watery  eyes, 
and  a  dry,  irritative,  laryngeal  coiigh,  sometimes  becoming  bronchial. 
Rarely  there  is  severe  and  obstinate  cough,  the  result  of  a  bronchial 
spasm,  with  little  or  no  secretion.  The  tongue  is  furred,  there  is 
anorexia,  epigastric  distress,  nausea,  occasionally  vojnititig,  and  often- 
times diarrhcea.  In  some  instances  the  digestive  symptoms  are  the 
most  prominent,  when  dysentery  may  occur.  Associated  with  either 
the  respiratory  or  digestive  form  of  attack  may  be  marked  disturb- 
ances of  the  cerebro-spinal  functions,  or  these  latter  may  be  the  most 
prominent  symptoms  present. 

The  above  symptoms   are  always  associated  with  depression  of 


20  PRACTICE    OF    MEDICINE. 

spirits,  and  a  debility  altogetlier  out  of  proportion  to  the  intensity  of 
the  fever  and  the  catarrhal  phenomena.  Delirium  is  rare,  but  marked 
hebetitde  and  cutaneous  hyperasthesia  are  common. 

Duration.  The  fever  declines  in  from  four  to  seven  days,  when 
begins  a  protracted  convalescence.  Relapses  frequently  occur,  and 
second,  third,  or  even  more  numerous  attacks  in  the  same  individual 
may  be  observed,  the  susceptibility  of  the  system  after  an  attack 
being  remarkable. 

Complications.  The  most  frequent  are  those  associated  with 
the  respiratory  organs.  Severe  bronchitis,  associated  in  the  feeble 
or  aged  with  fever,  typhoid  delirium,  and  tendency  to  oedema  of  the 
lungs.  Croupous  and  catarrhal  pneumonia  are  frecjuent  and  fatal 
complications.     Cerebro-spinal  meningitis  is  also  noted. 

Sequelae.  A  persistent  headache;  neuralgia;  neuritis;  insomnia; 
neurasthenia  or  a  confusional  insanity  ;  depression  of  spirits  often 
obstinate  and  needing  treatment ;  mania  ;  enlargement  of  lymphatic 
glands.  The  great  increase  in  pulmonary  phthisis  since  the  pan- 
demic of  1889-90  is  more  than  a  coincidence. 

Diagnosis.  Isolated  cases  maybe  mistaken  for  a  "  bad  cold." 
But  when  epidemic,  the  siddden  onset,  marked  general  catarrh,  and 
decided  prostration  should  prevent  error. 

At  the  onset  of  an  epidemic  Dengue  will  be  remembered.  Cerebro- 
spinal Fever  has  many  symptoms  in  common  with  the  nervous  form 
of  influenza. 

Prognosis.  Recovery  is  the  rule  w  hen  it  occurs  in  the  healthy 
and  vigorous  ;  according  to  Pepper  less  than  one-half  of  one  per  cent, 
die.  Crave  when  the  very  young,  the  very  old,  or  those  suffering  from 
organic  disease,  such  as  Bright's  disease,  fatty  heart,  emphysema,  or 
the  tubercular  diathesis,  are  attacked. 

Treatment.  No  specific.  During  the  prevalence  of  the  epi- 
demic influence  exposure  to  cold  should  be  avoided.  Support  the 
system  and  pursue  a  purely  symptomatic  method  of  medication. 
All  measures,  of  whatever  kind,  which  tend  to  depress  the  general 
nervous  system,  or  the  functional  activity  of  the  respiration,  and 
particularly  the  heart,  are  to  be  avoided.  Patients  should  be  kept  in 
bed  until  fever  declines  or  longer.  Keep  the  bowels  soluble.  If  many 
individuals  must  come  in  contact  with  the  patient,  some  isolation  and 
disinfection  of  the  nasal  and  bronchial  secretions  should  be  prac- 
tised. 


FEVERS.  21 

The  catarrh,  pains,  and  cotigh  are  at  least  ameliorated  by  the 
following : 

U.     Phenacetin. , gr.  iij  .2       Gm. 

Pulv.  camphone, gr.  j  .065  Gm. 

Caffeina  citrata, gr.  j  .065  Gm. 

Every  two  or  three  hours,  aUemated  with  qimiina  sulphas,  gr.  ij  (0.13 
Gm.). 

Excellent  results  follow  the  use  of  the  following  combination  : 

U .      Sodii  benzoat., ^ij  8.  Gm. 

Salol, 5  S3  2.  Gm. 

Phenacetin., gr.  xl  2.6       Gm. 

Strychninse  sulph., g^-  i  .012  Gm.  M. 

Ft.  chart,  vel  capsul.  No.  xij. 

SiG. — One  every  three  or  four  hours. 

Sodii  benzoas,  gr.  x  (0.65  Gm.)  every  four  hours,  is  strongly  recom- 
mended. 

During  the  last  pandemic  the  disease  was  frequently  aborted  in 
those  of  vigorous  health  by  a  few  ten-  or  fifteen-grain  (0.65-1  Gm.) 
doses  of  antipyrin,  although  in  those  of  feeble  resisting  power  much 
harm  resulted  from  the  indiscriminate  use  of  this  drug.  Dr.  Roland 
G.  Curtin  warmly  recommends  salicinum  as  coming  "  as  near  to  being 
a  specific  as  we  can  get  with  the  drugs  now  in  our  possession." 
QuinincE  sulphas,  in  full  doses  at  the  very  onset,  often  aborts  the 
disease. 

I  have  seen  excellent  results  in  neuralgic  cases  from  cinchonidincs 
salicylas,  gr.  v  (0.32  Gm.),  every  four  hours. 

The  frequent  inhalation  of  tinctura  benzoin,  comp.,  foss-j  (2-4 
Cc.)  in  aqucB  but.,  Gj  (475  Cc),  relieves  the  naso-pharyngeal  and 
bronchial  catarrh. 

If  the  bronchial  symptoms  become  troublesome,  use — 

JJ .     Ammonii  chlorid. , gr.  x  .65  Gm. 

Tinct.  hyoscyami, tr^xv  I.  Cc. 

Syr.  ipecac, TT\^v  .3  Cc. 

Spts.  frumenti, f^ss  2.  Cc. 

Aquae  chloroformi, f^iss  6.  Cc.  M. 

Every  three  or  four  hours,  diluted. 

The  complication  oi  pneumonia  requires  prompt  stimulating  treat- 
ment.    Dr.  Pepper  recommends  strychnines  sulphas  in  full  doses  as 


22  PRACTICE    OF    MEDICINE. 

tlie  most  important  remedy  against  this  complication,  and  suggests 
the  foliowintr  combination  as  often  valuable: 


Morjihina'  suliih., gr.  j  .065  G 

QuiniiKf  siilpli.,  . 


Slrjxliniiia'  suljih., 
Acid,  plios.  dil., 
Glyceritii,     .    .    .    . 
Aqucc 


gr.xxxv  2.3  Gm. 

gr.  ss  .03  Gm. 

{z^   iij  12.  Cc. 

fi  V  20.  Cc. 

q.  s.  ad  f  3  iij  90.  Cc.  M. 


SiG  — A  teaspoonful  four  to  six  times  daily,  in  water. 

Dr,  Bartholow  recommends  the  early  use  o{ pilocarpine ,  gr.  ^  (o.oi 
Gm.),  repeated  until  its  mild  physiological  effects  ensue,  when  it  is  sub- 
stituted by  duboisine,  gr.  ^Jij-^oiJ  (0.00022-0.00032  Gm.),  twice  a  day, 
and  for  the  depression  ferri  ioiiidum,  one  of  the  official  pills  every 
four  hours,  and  inhaling  one  or  two  drops  of  pyridine  every  few 
hours. 

During  convalescence  administer  st7ychnina  sulphas,  gr.  -^^ 
(0.0013  Gm.)  four  times  daily. 

Always  have  in  mind  that  influenza  is  often  the  exciting  cause 
of  a  phthisical  development  in  those  so  predisposed.  Insomnia  is  a 
symptom  calling  for  prompt  treatment.  The  anaemia  and  general 
weakness  of  convalescence  calls  ior  ferrum. 


TYPHOID   FEVER. 

Synonyms.  Enteric  fever  ;  gastric  fever  ;  nervous  fever ;  entero- 
mesenteric  fever  ;  abdominal  typhus  ;  autumnal  fever. 

Definition.  An  acute,  infectious  febrile  affection,  due  to  a. 
special  poison ;  characterized  by  insidious  prodromes,  epistaxis, 
dull  headache  followed  by  stupor  and  delirium,  red  tongue,  becom- 
ing dry,  brown,  and  cracked,  abdominal  tenderness,  early  diarrhoea 
and  tympany,  and  a  peculiar  eruption  upon  the  abdomen  ;  rapid 
prostration  and  slow  convalescence  ;  a  constant  lesion  of  Peyer's 
p.itches.the  mesenteric  glands,  and  enlargement  of  the  spleen. 

Causes.     Predisposing  and  exciting. 

The  chief  predisposing  causes  are  Age  and  Season.  It  is  claimed 
by  Pepper  that  a  particular  susceptibility  exists  in  certain  individuals 
and  families  to  typhoid  fever. 

The  most  frequent  age  is  between   fifteen  and  thirty  years,  and 


FEVERS,  23 

cases  are  rarely  seen  in  those  of  forty-five  years  and  over.  I  have 
seen  well-marked  cases  with  typical  symptoms  at  eighteen  months, 
and  at  five  years  of  age.  The  autumn  months  show  the  most  cases, 
and  particularly  following  a  hot  and  dry  summer. 

The  exciting  cause  is  a  special  typhoid  germ,  the  typhoid  bacillus 
or  bacillus  of  Eberth,  which  is  found  in  the  lesions  and  blood. 

The  poison  usually  results  from  the  deco7npositio7i  of  the  typhoid 
stools  and  the  sputum,  although  it  has  been  claimed  that  the  disease 
may  be  generated  under  certain  undetermined  circumstances,  de 
novo,  from  ordinary  filth  and  decomposition ;  this  view  has  less 
advocates  each  year. 

The  contagiousness  of  typhoid  fever  is  again  advanced. 

The  atmosphere  is  never  impregnated  with  the  fever  germ.  The 
poison  gains  its  entrance  into  the  system  by  means  of  infected  water, 
milk,  ice,  meat,  or  other  food.  The  germ  is  easily  destroyed  by 
thorough  disinfection  of  the  stools  and  sputum  with  heat,  mercuric 
bichloride,  or  acidum  carbolicum,  but  extreme  cold  will  not  destroy 
the  typhoid  germ. 

Pathological  Anatomy.  The  specific  anatomical  lesions  of 
typhoid  fever  are  invariably  present,  and  are  so  characteristic  that 
an  examination  of  the  body  after  death  will  in  any  case  make  known 
the  nature  of  the  disease,  even  had  the  symptoms  been  unknown. 
These  lesions  consist  in  changes  in  the  Peyerian patches  and  solitary 
glands,  which  may  be  divided  into  well-defined  stages,  as  follows  : 

First.  Stage  of  Infiltration,  or  Swelling  from  infiltration  and  ex- 
cessive proliferation  of  their  cellular  elements ;  the  surrounding 
mucous  membrane  is  also  infiltrated  with  cells.  The  Peyer's  patches 
are  thickened,  hardened,  and  elevated  above  the  mucous  membrane. 
The  number  of  patches  and  glands  involved  is  from  three  or  four  up 
to  nearly  the  entire  number.  The  above  changes  have  been  noted 
as  early  as  the  second  day. 

Second.  Stage  of  Necrosis,  Softening,  or  Sloughing  of  the  solitary 
and  agminate  glands.  Not  all  the  patches  necessarily  slough ;  in  a 
certain  number  of  them  the  morbid  changes  are  arrested  before  soft- 
ening. This  stage  constitutes  the  anatomical  changes  of  the  second 
and  third  week. 

Third.  Stage  of  Ulceration  following  and  depending  directly  upon 
the  softening  and  sloughing,  the  sloughs  gradually  separating,  begin- 
ning at  the  periphery  of  the  swollen  gland  and  finally,  at  about  the 


24  PRACTICE   OF    MEDICINE. 

end  of  the  third  week,  become  detached,  leaving  ulcers  of  various 
sizes. 

Foiirtli.  Stage  of  CicatrizLition,  or  in  rare  cases  Perforation.  The 
ulcer  gradually  diminishes  in  size,  the  surface  becoming  covered  with 
a  delicate  layer  of  granulations,  which  is  soon  transformed  into  con- 
nective tissue  and  covered  with  epithelium,  the  resulting  scar  being 
slightly  depressed.     The  gland-structure  is  never  regenerated. 

The  M.senteric  glands  become  infiltrated,  enlarged,  and  softened, 
but  seldom  ulcerate.  In  about  one-third  of  the  cases  the  large  intes- 
tine is  also  involved. 

The  Spleen  also  enlarges  and  softens,  the  increase  being  twice  or 
three  times  its  normal  size,  beginning  in  the  middle  of  the  first  week, 
and  reaching  its  height  at  the  end  of  the  second  week. 

There  are,  besides,  parenchymatous  degenerations,  or  granular 
changes  in  all  the  active  organs  and  tissues  of  the  body. 

Symptoms.  Stage  of  Prodromes. — The  onset  is  insidious,  with 
a  feeling  of  general  fnalaise,  vertigo,  headache,  particularly  occipital 
pain,  disordered  digestion,  disturbed  sleep,  epistaxis,  depression,  and 
muscular  weakness,  followed  by  a  chill  ox  chilliness,  iht  patient  being 
unable  to  designate  the  day  when  the  symptoms  began.  In  rare 
instances  the  disease  begins  abruptly  with  a  chill,  followed  by  high 
fever;  this  is  particularly  the  case  in  malarial  districts. 

The  exact  duration  of  these  premonitory  symptoms  is  not  known, 
and  may  be  said  to  vary  from  a  few  days  to  two  or  three  weeks. 

First  Week,  dates  from  the  onset  of  the  fever,  when  are  present  in- 
creasing temperature,  frequent  pulse,  headache,  listlessness,  the  eyes 
closed  as  if  asleep,  coated  tongue,  natisea,  diarrhaa  (there  may  be 
constipation),  the  abdomen  moderately  distended  and,  upon  pressure 
in  the  rigJit  iliac  fossa,  gurgling  sounds  and  tenderness.  Upon  the 
seventh  day  a  few  reddish  spots  resembling  flea  bites  appear  upon  the 
abdomen,  chest,  or  back. 

Second  Week.  The  foregoing  symptoms  are  exaggerated  ;  fever  is 
now  continuous,  with  a  frequent  and  compressible  and  dicrotic  pulse, 
tympanitic,  tender  abdomen ,  gurgling  in  the  right  iliac  fossa,  nocturnal 
delirium,  severe  and  constant  headache,  often  stupor,  a  short  cough 
with  distinct  bronchial  rales  on  auscultation,  irregular  muscular  con- 
tractions {subsultits  tendinum),  sordes  upon  the  teeth  and  lips,  tlie 
tongue  losing  its  coating  and  becoming  more  or  less  dry,  the  diarrhoea 
continuing.     During  this  stage  deafness   develops,  often  increasing 


FEVERS.  25 

until  profound,  and  continuing  into  convalescence.  Disturbances  of 
vision  are  frequent  in  pronounced  cases.    The  spleen  increased  in  size. 

Third  Week.  Fever  changes  from  continuous  to  remittent;  the 
evening  exacerbations  continue  as  high  as  the  preceding  week,  the 
morning  fall  growing  more  decided  each  day,  but  all  the  other  symp- 
toms remain  about  the  same  until  near  the  end  of  the  week,  when  a 
marked  amelioration  begins.  * 

In  a  fair  proportion  of  cases  all  the  symptoms  grow  worse  toward 
the  end  of  the  second  or  during  the  third  week.  The  prostration  is 
extreme,  the  stupor  so  marked  that  it  is  hardly  possible  to  rouse  the 
patient,  the  tongue  dry,  hard,  cracked,  and  covered  with  a  brown 
crust,  sordes  collect  on  the  gums,  teeth,  and  cracked  lips,  the  pulse  is 
rapid  and  feeble,  the  respirations  shallow  and  quickened,  retention 
of  urine,  which  contains  albumin.  The  stools  are  often  voided  invol- 
untarily, and  bed-sores  develop,  this  condition  terminating  in  death, 
or  passing  thus  into  the  fourth  week. 

Fourth  Week.  The  fever  decidedly  remits ;  almost  normal  in  the 
morning,  the  pulse  becoming  less  frequent  and  more  full,  the  tongue 
gradually  becoming  clean,  the  abdomen  lessens  in  size,  the  diarrhoea 
ceases,  the  patient  passing  into  a  slow  convalescence,  greatly  emaci- 
ated, which  convalescence  may  continue  for  several  weeks. 

Analysis  of  Symptoms.  The  temperature  record  of  typhoid 
fever  is  charactejistic.  The  fever  on  the  morning  of  the  first  day  may 
be  stated  at  98.5°  F.,  evening  100.5°;  second  morning  99.5°,  evening 
101.5°;  third  morning  100.5°,  evening  102.5°;  fourth  morning  101.5°, 
evening  103.5°;  fifth  evening  104.5°.  From  that  time  until  end  of  the 
second  week  the  evening  temperature  ranges  between  103°  and  105°, 
the  morning  temperature  being  a  degree  or  more  lower.  During  the 
second  or  third  week  hyperpyrexia,  or  fever  above  105°  F.,  may 
develop  and  adds  to  the  gravity  of  the  attack.  A  high  temperature 
during  the  third  and  fourth  week  is  of  grave  import.  Temperatures 
of  io6°-io7°  with  recovery  are  reported,  but  they  must  be  rare. 

Afebrile  cases  of  typhoid  fever  are  reported,  all  other  symptoms 
with  the  prostration,  but  the  step-like  temperature,  being  present. 

Diarrhoea  is  the  principal  intestinal  symptom  ;  if  absent,  the  lesion 
may  be  slight.  The  stools  are  ai  first  dark,  but  early  in  the  second 
week  they  become  fluid,  offensive,  ochre-yellow  in  color,  resembling 
"peasoup,"  and  maybe  streaked  with  blood  They  number  from 
three  \.o  fifteen  during  the  twenty-four  hours. 


26  PRACTICE    OF   MKDICINE. 

Constipation  occurs  more  frequently  than  is  supposed.  I  have 
seen  one  hundred  cases  with  constipation  within  the  past  ten  years. 

The  urine  has  the  ordinary  febrile  characters.  Retention  is  very 
common.  Ehrlich'  describes  a  reaction  which  he  believes  is  rarely 
met  with  save  in  typhoid  fever.  In  examinations  of  the  urine  by 
Ehrlich's  diazo-reaction  in  fifty  cases  of  typhoid  fever  in  the  wards  of 
the  Philadelphia'Hospital,  the  reaction  was  found  in  thirty-eight,  h 
has  also  been  found  in  a  number  of  other  conditions,  particularly 
those  having  gastro-intestinal  symptoms. 

Eruption  is  almost  constant.  Consists  of  fromy?7/<?  to  /a/^«/y  small, 
rose-colored  spots  on  the  abdomen,  chest,  or  back,  sometimes  on  the 
limbs,  appearing  in  crops,  lasting  about  y?z/<f  days,  disappearing  on 
pressure  and  at  death.  Returning  with  relapses.  Eruption  day 
from  the  seventh  to  the  ninth. 

Rarely  spots  of  a  delicate  blue  tint — the  "  taches  bleuatres  "  of 
French  authors — are  observed. 

Nervous  symptoms  are,  pronounced  headache,  early  and  severe, 
dullness  of  intellect  soon  following,  passing  into  drowsiness  and 
stupor,  with  great  prostration.  Deafness  pronounced.  Sight  im- 
paired, and  in  grave  cases  double  vision.  Delirium  low  and  mutter- 
ing, generally  pleasant  in  character;  always  present  in  severe  cases. 
Coma  vigil  \5  a  grave  symptom,  the  patient  lying  perfectly  quiet  with 
eyes  open,  taking  no  heed  to  his  surroundings. 

Splenic  enlargement  is  an  almost  constant  clinical  feature.  A  ver- 
tical dullness  exceeding  two  ribs  and  an  interspace  signifies  enlarge- 
ment. Palpation  is  a  valuable  aid  for  determining  splenic  enlarge- 
ment. 

Muscular  symptoms  are  developed  late  in  the  second  or  early  in 
the  third  week,  and  consist  of  irregular  contractions,  carphologia,  or 
subsultus  tendinum,  and  are  the  result  of  the  great  debility.  The 
reverse  of  muscular  contractions,  to  wit,  lying  perfectly  motionless 
in  bed,  attempting  no  muscular  effort  of  any  kind,  is  a  grave  sign. 

Convalescence  shows  great  debility  and  emaciation,  extreme 
anaemia,  and  severe  nervousness,  often  very  protracted.  It  is  during 
convalescence  that  irritability  of  the  heart,  profuse  night-sweats,  and 
insomnia  occur,  and  in  women  loss»of  hair. 

Complications.  Intestinal  hemorrhage  is  the  most  frequent 
and  at  times  the  most  critical  of  any  of  the  complications  of  typhoid 
fever.     The  hemorrhage  may  occur  any  time  between  the  fourteenth 


FEVERS.  27 

and  twentieth  day  ;  a  sudden  decline  of  the  temperature  to  the  norm 
or  below  frequently  precedes  the  passage  of  blood  by  stool.  The 
hemorrhage  is  due  to  the  erosion  of  a  vessel  during  the  ulcerative 
stage. 

Perforation  makes  the  case  almost  hopeless.  Peritonitis  without 
perforation  adds  to  the  gravity,  but  is  not  necessarily  fatal. 

Lobar  pneumonia,  hypostatic  congestion,  and  brofichitis  are  fre- 
quent occurrences.  There  are  few  cases  that  do  not  have  slight 
bronchial  cough  from  the  onset.  Albiwiinuria  and  aciite  nepJiritis 
may  occur,  as  v^-d.y  phlegmasia  dolens,  the  result  of  thrombosis  of  the 
femoral  vein,  usually  the  left.  Bed-sores  are  frequent,  resulting  from 
the  impaired  nutrition,  emaciation,  and  pressure  over  bony  promi- 
nences, and  the  difficulty  of  keeping  the  patient  clean. 

Ulceration  of  the  tongue  and  mucous  membrane  of  the  cheek  is 
sometimes  seen. 

Sequelae.  Paralysis, — either  mono-  or  paraplegia, — due  to  an  acute 
neuritis.  Post-febrile  insanity  occurs  more  frequently  after  typhoid 
than  any  other  febrile  condition,  save  influenza.  Acute  Nephritis 
associated  with  oedema.  Alopecia,  complete  or  partial.  Trans- 
verse markings  of  the  nails.  Tuberculosis  may  develop  in  those 
predisposed. 

These  sequelae  of  typhoid  fever  are  all  the  result  of  the  impaired 
nutrition  and  great  prostration. 

Relapses  are  coramon.  Da  Costa  reporting  five  in  one  patient, 
and  Wilson  (J.  C.)  four  in  one  of  his  cases.  The  symptoms  all  return 
abruptly  ;  the  duration  is  half  the  time  of  the  original  attack  ;  occur 
at  the  end  of  the  fourth  or  beginning  of  the  fifth  week.  Not  so  fatal 
as  generally  supposed. 

Abortive  typhoid  fever  z-re.  cases  of  mild  character,  having  many 
of  the  typical  symptoms,  running  its  course  in  about  two  weeks.  The 
so  called  walking  cases  are  often  of  this  character. 

Diagnosis.  The  Widal  reaction  or  serum-test  gives  brilliant 
promise  for  the  early  and  correct  diagnosis  of  the  disease.  Widal 
and  others  showed  that  "if  to  a  drop  of  blood-serum,  or  to  a  drop 
of  water  containing  a  solution  of  dried  blood  from  a  typhoid  patient, 
a  moderate  number  of  typhoid  bacilli  were  added,  a  peculiar  reaction 
occurred,"  seen  under  the  microscope  as  a  loss  of  the  natural  motility 
and  an  agglutination  of  the  bacilli — a  clumping  into  masses. 

An  error  that  is  constantly  being  made  is  that  of  confounding 


28  PRACTICE    OF    MEDICINE. 

typhoid  fever  with  the  typhoid  (depressing)  symptoms  or  conditions 
developing  during  the  course  of  many  acute  diseases.  The  absence 
of  the  characteristic  diarrhcca,  the  peculiar  eruption,  and  the  typi- 
cal temperature  record  and  enlarged  spleen  should  prevent  the 
error. 

Enteritis  has  intestinal  derangement  and  an  irregular  fever  course. 

Peritonitis,  abdominal  symptoms  only,  with  constipation  and  rapid 
eaily  prostration  and  collapse. 

Acute  miliary  tuberculosis  is  often  mistaken  for  typhoid  fever,  an 
error  difficult  to  prevent  at  times.  The  perfection  of  the  Widal 
reaction  and  diazo-urine  reaction  may  remove  the  doubtful  points 
in  the  near  future. 

Meningitis  lacks  the  intestinal  symptoms  and  fever  record. 

The  so-called  typho-malarial  or  malaria  typhoid  fever  has  many 
symptoms  in  common,  but  lacks  the  diarrhoea,  eruption,  and  temper- 
ature record. 

Prognosis.  A  positive  prognosis  cannot  be  made.  Favorable 
indications  are  constipation,  or  slight  diarrhoea,  low  temperature,  and 
moderate  delirium.  Unfavorable  symptoms  are  obstinate  and  severe 
diarrhoea,  early  high  temperature,  cardiac  exhaustion,  marked  ner- 
vous symptoms  with  coma  vigil  or  stupor,  albuminuria,  and  repeated 
intestinal  hemorrhages. 

The  prognosis  is  always  more  favorable  in  winter  than  in  summer. 

When  death  occurs,  it  is  usually  during  or  about  the  third  week, 
the  result  of  exhaustion,  cardiac  failure,  or  some  complication. 
Children  under  puberty  usually  recover.  More  women  than  men 
die,  although  less  women  have  the  disease.  Pregnant  women  and 
fleshy  people  usually  succumb. 

The  mortality  in  typhoid  fever  in  private  practice  is  about  one 
death  in  twenty ;  in  hospital  practice  it  varies  from  one  death  in  five 
to  ten  cases,  although  the  cold  bath  treatment  has  greatly  reduced 
the  hospital  mortality. 

Treatment.  There  is  no  specific  treatment  for  typhoid  fever. 
The  indications  are  to  sustain  life  and  meet  the  urgent  and  danger- 
ous symptoms  as  they  arise. 

Flint  held  that,  as  it  was  a  self-limited  disease,  "  if  the  patient  can 
be  kept  alive  after  three,  four,  or  more  weeks,  recovery  will  take 
place  provided  there  be  no  serious  complication.  In  a  case  of  severe 
uncomplicated  fever  the  patient  is  in  a  situation  not  unlike  that  of  a 


FEVERS.  29 

person  in  danger  of  drowning  not  far  from  or  perhaps  very  near  the 
shore.  If  he  drown,  it  is  because  his  strength  gives  way  before  the 
shore  is  reached.  As  a  person  in  this  situation  requires  only  to  be 
buoyed  up  by  some  support,  so  the  fever  patient  in  a  similar  emer- 
gency may  only  need  supporting  measures  to  live." 

It  is  important  to  secure  intelligent  nursing,  a  quiet,  airy  sick- 
room with  an  average  temperature  of  65°  F.,  and  the  most  scrupu- 
lous cleanliness  of  patient,  bedding,  and  utensils.  The  patient 
must  go  to  bed  from  the  moment  of  suspicion  that  typhoid  fever  is 
developing,  and  remain  in  bed  until  convalescence  is  well  established. 

The  stools  and  iiri7ie  must  be  disinfected  the  moment  voided,  and 
quickly  discharged  into  a  sewer  or  buried. 

The  diet  should  be  nutritious  and  liquid  at  intervals  of  every  two 
or  three  hours.  Diluted  milk  is  the  best  article,  but  broths,  soups, 
liquid  peptonoids,  coffee,  and  cold  milk  and  tea  may  be  alternated. 
A  word  of  caution,  however,  as  to  the  quantity  of  food  administered. 
The  amount  should  be  small,  as  the  digestive  capacity  of  the  patient 
is  greatly  lessened  by  the  febrile  phenomena.  Much  harm  results  in 
typhoid  fever  from  stuffing  the  patient.  Watch  stools  for  undigested 
milk. 

The  tendency  to  bed-sores  must  be  kept  in  mind.  The  use  of  finely 
powdered  boric  acid  over  irritated  parts  will  often  prevent  their  devel- 
opment, or  if  developed,  are  healed  by  constant  applications  of  bov- 
inine  on  several  layers  of  gauze. 

Attention  should  be  given  to  the  mouth,  and  the  dryness  and  ten- 
dency to  collections  of  sordes  prevented  by  frequently  washing  with 
glycerine  and  water  or  weak  boric  solution. 

The  following  remedies  have  advocates,  claiming  that  they  modify 
the  course  of  the  disease :  hydrargyrum,  iodum,  acidian  carbolicum, 
mineral  acids,  argentutn  nitras,  guaiaciwi ,  and  ergota,  but  no  one  drug 
can  claim  specific  action. 

The  reduction  of  temperature  is  one  of  the  most  important  indica- 
tions in  the  majority  of  cases  of  typhoid  fever.  There  is  now  no 
doubt  that  the  former  views  regarding  the'  amount  of  fever  a  patient 
could  stand  for  one  or  two  weeks  are  responsible  for  the  high  mor- 
tality in  this  disease,  A  temperature  of  103°  to  105°  for  a  dozen  days 
is  dangerous  and  should  be  combated.  Among  the  measures  that 
have  been  used  with  success  in  many  instances  is  quinincE  sulphas, 
gr,  xv-xx  (i-i. 3  Gm.),  morning  and  night.    A  strong  prejudice  has 


30  PRACTICE    OF    MEDICINE. 

arisen  against  quinina  within  the  last  few  years,  nevertheless,  I  know 
I  have  seen  great  benefit  from  its  use,  and  strongly  recommend  it. 
Cold  sponging  with  water  alone  or  alcohol  and  water  is  often  of 
great  value  in  mild  cases,  and  when  sponging  it  is  essential  to  leave 
the  surface  very  wet.  The  cold  pack  is  a  very  powerful  antipyretic 
and,  in  cases  with  temperature  of  104°  or  105°,  in  which  the  cold  bath 
cannot  be  employed,  can  be  made  use  of.  The  bed  should  be  pro- 
tected by  a  rubber  cloth,  and  the  patient,  with  his  clothing  removed, 
should  be  wrapped  in  a  sheet  wrung  out  of  cold  water.  The  surface 
should  be  rubbed  briskly  through  the  sheet,  and  from  time  to  time 
cold  water  is  freely  sprinkled  over  the  sheet.  Friction  must  be  con- 
tinued during  the  pack,  and  ice  cloths  or  cap  placed  on  the  head. 
The  duration  of  the  cold  pack  is  determined  by  the  temperature  and 
the  reactive  powers  of  the  patient.  It  is  often  well  to  administer  an 
alcoholic  stimulant  or  a  hypodermic  injection  of  strychninae  sulphas 
before  the  pack  and,  may  be,  after. 

The  cold  bath,  after  the  method  of  Brand,  or  "  tubbing,"  has  proven 
most  prompt  and  decided  for  reducing  temperature.  It  consists  in 
the  systematic  employment  of  general  cold  baths,  with  frictions  when- 
ever the  temperature  reaches  102.2°  F.  As  often  as  the  temperature, 
taken  every  three  hours  in  the  mouth  or  rectum,  is  over  102.2°,  the 
patient  receives  a  bath  lasting  fifteen  or  twenty  minutes.  He  wears  a 
thin  muslin  garment  or  is  wrapped  in  a  sheet ;  he  is  given  a  stimulant 
and  carefully  lifted  into  the  bath  of  65°  or  70°,  some  cold  water  being 
poured  over  his  head  and  shoulders  to  lessen  the  shock ;  the  head 
rests  on  an  air  pillow,  the  body  submerged  to  the  neck.  During  the 
luhole  period  of  the  bath  the  patient  intist  be  briskly  rubbed.  The 
friction  and  affusion  are  of  value  in  preventing  chill  and  cyanosis. 
After  the  bath  the  wet  linen  is  quickly  removed  and  the  patient  placed 
in  bed  wrapped  in  a  dry  sheet  and  covered  with  a  blanket.  A  stimu- 
lant is  again  given  after  the  bath,  and  if  a  tendency  to  cyanosis  or  hear! 
failure,  a  hypodermic  injection  of  strychnina.  The  temperature  is 
taken  after  the  patient  is  placed  in  bed  and  again  in  half  to  three- 
quarters  of  an  hour,  and  if  not  then  102°,  is  not  again  taken  for  three 
hours.  The  good  effects  of  the  bath  are  seen  in  a  reduction  of  tem- 
perature, clearer  intellect,  and  lessening  stupor  and  muscular  twitch- 
ing. Sleep  usually  follows  a  bath,  with  a  general  stimulating  effect 
upon  the  heart  and  the  nervous  system.  There  are  no  counter- 
indications  to  the  cold  bath  save  intestinal  hemorrhage. 


FEVERS.  31 

Diarrhoea  should  not  be  checked  unless  it  exceeds  three  or  four 
stools'va.  twenty-four  hours,  when  may  be  used — 

R .      Bismuth,  subnit., gr.  xx  1. 3  Gm. 

Acid.  carboL, Tl\j  .06  Cc. 

Tinct.  opii  deodorat. , Ti\xv  I.  Cc. 

Mucil.  acacise, f^j  4.  Cc. 

Aquae,      fSiij  12.  Cc.  M. 

SiG. — Every  three  or  four  hours. 

Or— 

R.     Cupri  sulph., g*"-  5^  -Oil  Gm. 

Extract!  opii, gr-  X  •'-'^^  Qra..        M. 

SiG. — In  pill,  every  four  hours. 

At  the  onset  of  a  suspected  case  of  typhoid  fever,  when  there  are 
present  coated  tongue,  fetid  breath,  anorexia,  chilliness  followed  by 
feverishness  or  fever,  nervousness,  costiveness  or  frequent  tenesmic 
stools,  and  general  soreness  associated  with  mental  unrest  and  head- 
ache, excellent  results  follow  the  use  of  the  following  combination  : 

R-      Hydrargyri  chlor.  mite,      ....    gr.  viij  .52    Gm. 

Sodii  bicarbonatis, gr.  xv  I.         Gm. 

Pulv.  ipecacuanhse, gr-  ij  -13     Gm. 

Salol, gr.  XV  i.         Gm.        M. 

Ft.  chart.  No.  xv. 

SiG. — One  powder  every  three  hours  until  decided  bowel  action. 

Or— 

R.     Salol, .    .    gr.  iij  .2      Gm. 

Bismuth,  salicyl.,  basic,     .    .    .    .     gr.  v  .3       Gm.         M. 

SiG. — In  powder,  after  each  stool. 

Or— 

R .     Acid,  sulph.  aromat., TT\^xv  I.         Cc. 

Tinct.  opii  deodorat., ITLx  .6      Cc. 

SiG. — In  water,  every  three  hours. 

For  Tympanites :  cold  compresses  or  an  ice-bag  to  the  abdomen, 
or  a  turpentine  stupe  is  of  value.  Page  recommends  the  gentle 
introduction  of  a  catheter  far  up  the  rectum  to  relieve  a  powerless 
bowel,  as  urine  is  drawn  from  a  paralyzed  bladder.  Tympany 
with   constipation   is   relieved   by  the   use  of  olei  terebinthincE,  Ti^x 


32  PRACTICK    OF    MEDICINE. 

(0.6  Cc),  olei  ricini,  itlxv  (i  Cc),  in  emulsion  every  three  or  four 
hours. 

For  Thirst:  cooling  drinks  in  moderation,  or  pellets  of  ice  slowly 
dissolved  in  the  mouth,  and  washing  mouth,  lips,  and  tongue  fre- 
quently with  cold  water  is  acceptable. 

Headache :  cold  to  the  head,  mustard  to  the  neck,  and  foot  baths; 
if  these  fail  to  relieve,  iitorphina  or  atrophia  hypodermically,  and 
rarely  leeches  to  the  temples  may  be  needed. 

Delirium  :  if  from  debility,  increase  the  stimulants  ;  other  causes, 
use  morphina  if  the  delirium  is  active. 

InsoiJinia:  if  of  long  duration,  use  trional,  gr.  xv-xxx  (1-2  Gm.). 

Restlessness  and  coma  vit^il :  sti}nula7its  and  an  ice  cap. 

Debility :  food  every  two  or  three  hours ;  do  not  permit  sleep  to  in- 
terfere with  nourishment.  Stimulants  are  indicated  early,  the  best 
guide  being  the  heart's  action  ;  an  average  amount  would  be  spiri- 
tus/rumenti,  f^ss  (15  Cc.)  every  three  hours,  but  the  amount  and  fre- 
quency of  the  dose  must  be  guided  by  the  condition  of  the  heart, 
pulse,  and  general  prostration.  Spiritus  amtnoiiice  aromaticus,  f3j 
(4  Cc.)  every  couple  of  hours  in  milk  or  water,  is  a  valuable  stimu- 
lant and  stomachic  tonic.  Spiritus  chloroformi,  Tr^ij-v  (0.12-0.3  Cc.) 
every  hour  or  two,  is  also  a  valuable  stimulant. 

The  bladder  should  be  examined  at  each  visit. 

Intestinal  hemorrhage  :  at  once  tnorphina,  hypodermically,  and 
ext.  ergotcB  fld.,  i^]  (4  Cc),  repeated  p.  r.  n.,  or  Monsel's  solution, 
Ti^v-x  (0.3-0.6  Cc.)  every  two  hours,  or  olei  terebinthina:,  ir^x  (0.6  Cc), 
and  cold  to  the  abdomen. 

Perforation  and  peritonitis :  at  once  morphina  sulphas,  gr.  yi 
(0.032  Gm.),  hypodermically,  followed  by  extractum  opii,  gr.  j  (0.065 
Gm.)  every  hour,  hot  applications  to  the  abdomen,  and  bold  stimula- 
tion. 

Lobar pnetimonia  and  bronchial  catarrh  :  dry  cups  and  the  use  of 
the  following: 

R.     Ammonii  chlorid., gij  8.         Gm. 

Stryclinina;  sulph  , gr.  y^  .02    Gm. 

Spts.  chloroformi,       fzj  4.         Cc. 

Aq.  lauro-cerasi,    .    .    .    q.  s.  ad  f.^iv  120.         Cc. 

SlG. — Dessertspoonful  every  two,  three,  or  four  liours,  diluted. 

In  cases  in  which  the  tongue  is  dry,  brown,  and  with  a  tendency 


FEVERS.  33 

to  fissure,  excellent  results  are  obtained  from  turpentine  in  emul- 
sion : 

R.     Olei  terebinthinse, f^ss  15.  Cc. 

Mucil.  acacise, q.  s.  q.  s. 

01.  sassafras, Tr^xv  I.  Cc. 

Aq.  chloroformi,     .    .    .     q.  s.  ad   i^iv  120.  Cc.                 M. 
One  teaspoonful  every  two  or  three  hours,  diluted. 

In  patients  with  whom  the  above  disagrees,  good  results  are  ob- 
tained from  acidum  hydrochloricum  dilutum  or  one  of  the  other  of  the 
mineral  acids,  in  doses  of  Tr^xv  (0.9  Cc),  well  diluted  every  three  or 
four  hours. 

During  the  entire  course  of  the  disease  use  strychnincB  sulphas, 
gr.  -^  (0.002  Gm.),  every  four  hours. 

Convalescence  :  The  patient  must  be  most  guarded  in  exercise  or 
mental  occupation.  Liquid  diet  for  ten  days  to  two  weeks  after  nor- 
mal afternoon  temperature.  Cardiac  palpitation  and  excessive  sweat- 
ing are  not  infrequent,  and  can  be  controlled  by  a  combination  of 
quinina  and  belladonna.  If  the  stools  continue  quite  liquid  with  a 
little  bright  blood  now  and  then,  showing  some  remaining  ulceration, 
use  argentuni  nitras  in  pill  form  with  nucis  vo7mccz  or  strychnina. 
The  addition  of  extract  of  malt  or  porter  to  the  diet  is  of  value  in  a 
prolonged  convalescence. 

TYPHUS  FEVER. 

Synonyms.  Contagious  fever  ;  ship  fever  ;  jail  fever ;  exanthe- 
matic  typhus  (German)  ;  petechial  typhus  ;  spotted  or  putrid  fever. 

Definition.  An  acute,  infectious,  febrile,  epidemic  disease ;  highly 
contagious,  and  characterized  by  sudden  invasion,  profound  depres- 
sion of  the  vital  powers,  sickening  odor,  and  a  peculiar  maculated 
and  petechial  eruption,  favorable  cases  terminating  by  crisis  about 
the  fourteenth  day.     No  lesion. 

Cause.  A  special  infecting  germ,  the  character  of  which  is  un- 
known, but  which  is  influenced  by  filth  and  overcrowding.  Rarely 
seen  in  the  United  States  except  in  seaports,  where  brought  by  emi- 
grants. 

Pathology.     No  constant  lesion  peculiar  to  the  affection.     Blood 
is  profoundly  altered,  dark,  thin,  with  lessened  fibrin  ;  tissues  dark, 
soft,  and  flabby. 
3 


34  PRACTICE    OF    MEDICINE. 

Symptoms.  Begins  abruptly  ;  chill  followed  by  violent  fever, 
teinpcrature  within  a  few  days  reaching  104°  to  105°  F. ;  a  frequent, 
bounding  pulse,  soon  becoming  small,  weak,  and  rapid  ;  the  cardiac 
impulse  and  first  sound  almost  effaced,  severe  headache,  followed  by 
\'\o\tn\.  deliriian ;  from  \\\q  fifth  to  the  seventh  day,  a  coarse,  red, 
diffused,  measly  eruption,  with  a  mottling  of  the  skin  all  over  the 
body,  except  the  face,  not  disappearing  on  pressure ;  the  face  has  a 
uniform  deep,  dusky  flush,  the  skin  has  a  glazed  appearance,  the 
pupils  are  contracted,  the  eyes  injected.  With  the  development  of 
the  disease  there  is  cutaneous  hyperesthesia,  muscular  soreness,  and 
tenderness  over  the  tibia.  There  is  gyeaX.  prostration,  great  muscular 
feebleness,  vertigo,  tremor,  and  subsultiis  ;  constipation  the  rule.  End 
of  the  second  week,  the  temperature  suddenly  declines  and  the 
patient  passes  into  a  rapid  convalescence. 

Complications.  Pneumonia  and  swollen  parotid  glands  are 
common. 

Diagnosis.  From  typhoid  fever,  the  age,  season,  onset  of  the 
disease,  temperature  record,  character  of  the  eruption,  and  the  intes- 
tinal symptoms. 

Measles  begin  milder,  with  coryza  and  cough,  and  never  have  such 
pronounced  nervous  phenomena,  but  there  occurs  an  early  eruption, 
appearing  on  the  face. 

Cerebrospinal  fever  has  many  symptoms  in  common,  and  but  for 
the  rarity  of  typhus  in  this  country  would  be  more  puzzling.  The 
headache  and  rigidity  of  the  muscles  of  the  neck  are  much  more  pro- 
nounced in  cerebro-spinal  fever  and  the  prostration  less  than  in 
typhus  fever.  The  eruption  of  typhus  is  characteristic  and  should 
prevent  error. 

Prognosis.  Unfavorable  indications  :  high  temperature,  frequent 
pulse,  early  stupor,  presentiment  of  death.  Favorable  :  youth,  mod- 
erate temperature  and  pulse,  and  mild  nervous  phenomena. 

The  duration  about  two  weeks  ;  mortality  varies  from  five  to  thirty- 
five  per  cent. 

Treatment.  Symptomatic.  As  /y^/z^^ /<?7/<fr  is  distinctly  conta- 
gious, isolation  is  imperative,  with  immediate  removal  and  disinfection 
of  the  patient's  excreta. 

All  cases  are  benefited  by  small  doses  of  the /«/«i?r«/a(rzV/5  alternat- 
ing with  quinince  sulphas. 

For  kieh  temperature,  cold  sponging,  cold  pack,  or  full  doses  of 


FEVERS.  35 

quinince  sulphas.  Also  the  systematic  use  of  the  cold  bath  or  "  tub- 
bing," as  now  employed  in  typhoid  fever. 

For  the  headache  and  deliriutn  cold  to  the  head.  In  the  young 
and  strong,  a  few  leeches  to  the  temple,  and  chloral,  with  or  without 
the  bromides. 

For  constipation,  mild  laxatives. 

Debility  :  alcohol  early  and  in  full  doses,  or  spiritus  chloroformi  in 
drachm  doses  whenever  danger  of  collapse. 

Convalescence  :  such  tonics  as  quinitia  and  strychnina. 


CEREBRO-SPINAL  FEVER. 

Synonyms.  Epidemic  cerebro-spinal  meningitis  ;  epidemic  cere- 
bro-spinal  fever ;  spotted  fever ;  cerebro-spinal  typhus. 

Definition.  A  malignant  epidemic  fever,  characterized  by  head- 
ache, vomiting,  painful  contractions  of  the  muscles  of  the  back  of 
the  neck,  retraction  of  the  head,  hyperaesthesia,  disorders  of  the 
special  senses,  delirium,  stupor,  coma,  and  frequently  an  eruption  of 
petechiee  or  purpuric  spots — a  subcutaneous  extravasation  of  blood. 
Lesions  of  cerebral  and  spinal  membranes  are  found  at  the  post- 
mortem. 

Cause.  A  special  micro-organism,  of  oval  shape,  occurring  mostly 
in  pairs  and  faintly  tremulous,  resembling  those  found  in  pneumonia 
and  erysipelas,  though  hardly  identical.  Bad  hygiene  seems  to  favor 
the  development  of  this  affection,  but  can  hardly  be  considered  its 
cause. 

The  disease  seems  to  have  a  predilection  for  the  young.  Occurs 
most  frequently  in  the  winter  months.     Slightly  if  at  all  contagious. 

We  have  no  positive  knowledge  of  the  manner  in  which  the  virus 
gains  entrance  into  the  system. 

Pathological  Anatomy.  The  extent  of  lesion  present  in  a 
given  case  depends  upon  the  duration  of  the  illness.  In  cases  rapidly 
fatal  it  is  probable  that  the  individual  is  overwhelmed  by  the  poison 
ere  the  characteristic  anatomical  changes  have  had  time  to  develop. 

The  changes  in  this  disease  are  twofold:  those  due  to  the  direct 
action  of  the  infecting  poison  upon  the  blood,  producing  the  group  of 
symptoms  constituting  the  fever  and  complications,  and  those  giving 
rise  to  the  local  inflammation — viz.,  hypercemia  of  the  membranes  of 


36  PRACTICE    OF   MEDICINE. 

the  brain  and  spinal  cord,  followed  by  an  exudation  of  lymph  and  an 
effusion  of  scruvt,  resulting  in  pressure  upon  the  brain  and  cord.  The 
inflammatory  changes  are  more  marked  in  the  membranes  at  the 
base  of  the  brain  than  elsewhere.  The  lungs,  spleen,  stomach,  liver, 
kidneys,  and  bladder  are  in  various  stages  of  congestion. 

If  the  patient  survive  long  enough,  inflammatory  changes  occur  in 
the  cranial  and  special  nerves  and  the  organs  of  special  sense. 

Symptoms.  Divided,  according  to  the  severity  of  the  lesion, 
into  three  groups  :  the  common  iorm ,ihe  fu/minant,  and  the  abortive. 

The  Common  Form  begins  abruptly  with  a  r//z'//,  excruciating  head- 
ache, persistent  nausea,  vomiting,  7'ertigo,  and  an  overwhelming  sense 
of  weakness.  Within  a  few  hours  the  muscles  of  the  back  of  the 
neck  become  rigid  and  retracted  (tonic  spasm),  with  decided  pain 
upon  moving  the  head ;  this  rigidity  and  retraction  soon  extends  to 
the  back,  when  opisthotonus  occurs.  There  is  great  restlessness,  and 
the  surface  of  the  body  becomes  highly  sensitive  {hyperesthesia). 
Cramps  in  the  muscles  of  the  legs  and  elsewhere,  and  spasmodic 
twitchings  of  the  lips  and  eyelids  come  and  go,  and,  finally,  convul- 
sions or  delirium  occur.  Intolerance  of  light,  and  in  some  cases 
amaurosis,  more  or  less  deafness,  loss  of  sense  of  smell  and  taste 
soon  following.  The  temperature  and  pulse  records  are  irregular. 
From  \}s\&  first  day  to  the  fifth  an  eruption  of  petechiae  or  purpura 
occurs  in  the  majority  of  cases,  and  also  an  herpetic  eruption,  begin- 
ning as  herpes  labialis,  appears.  The  tache  cerebrale  is  usually  to  be 
obtained.  The  disease  reaches  its  height  in  from  three  to  eight  days, 
and  passes  into  stupor  and  coma,  or  ameliorates  and  passes  into  a 
protracted  convalescence. 

The  Fuhninant  Form.  Severe  chill,  depression,  and  in  a  few  hours 
collapse.     The  patient  is  overcome  by  the  poison  and  never  reacts. 

The  Abortive  Form  consists  of  one  or  more  pronounced  character- 
istic symptoms  during  the  course  of  an  epidemic. 

Complications.  Pneumonitis;  endocarditis;  pericarditis;  typhoid 
fever;  pleuritis  ;  intestinal  catarrh  in  infants. 

Sequelae.  Result  from  thickening  of  either  the  cerebral  or  spinal 
membranes.  Persistent  headache ;  blindness,  or  deafness,  partial  or 
complete;  mental  feebleness;  chronic  hydrocephalus;  epilepsy,  or 
different  forms  of  spinal  palsies. 

Diagnosis.  Typhoid  fever  begins  slowly,  has  a  characteristic 
temperature  record,   without   so    intense  headache,   and    muscular 


FEVERS.  37 

rigidity,  opisthotonus,  vomiting,  and  early  delirium,  not  ending  in 
coma. 

Typhus  fever  has  higher  temperature,  is  of  longer  duration,  and  has 
a  peculiar  measly  eruption,  is  not  attended  with  muscular  rigidity  and 
retraction,  hyperaesthesia,  nor  disorders  of  the  special  senses. 

Tubercular  me7iingiiis  is  not  epidemic,  has  no  characteristic  erup- 
tion ;  is  preceded  by  long  prodromes,  and  runs  a  tedious  course. 

A  congestive  chill  resembles  the  fulinifiant  cases  in  suddenness  of 
depression,  but  the  latter  has  not  the  history  of  the  former. 

Inflammation  of  the  metiinges  of  the  cord  is  due  to  exposure  to 
cold  or  syphilis,  and  is  not  attended  with  cerebral  symptoms  or  an 
eruption. 

Small-pox  in  the  first  days,  with  the  severe  lumbar  pains,  headache, 
vomiting,  and  rash,  may  cause  error. 

ProgTlOSis.  Varies  according  to  epidemic ;  from  twenty  to  fifty, 
and  even  seventy-five  per  cent.  die. 

Treatment.  There  is  no  abortive  plan  of  treatment  for  cerebro- 
spinal fever,  nor  can  the  antiphlogistic  treatment  for  the  inflammatory 
symptoms  be  advised.  Like  the  infectious  diseases  in  general,  sus- 
taining measures  are  indicated  in  all  but  the  most  sthenic  cases. 

Nutritious  and  easily  assimilated  food,  such  as  milk,  eggs,  meat- 
juice,  and  broths,  should  be  given  at  regular  intervals  night  and  day. 
If  food  cannot  be  taken  by  the  mouth,  nutritious  enemata  should  be 
substituted. 

The  drug  that  holds  the  highest  place  in  the  treatment  of  this  dis- 
ease is  opium.  The  hypodermic  use  of  morphitice  sulphas,  gr.  yi-Yz 
(0.016-0.032  Gm.)  every  two  or  three  hours,  or  extraxttan  opii,  gr.  j 
(0.065  Gm.)  every  hour  until  the  stage  of  effusion,  when  quinincE 
sulphas  in  tonic  doses,  z.Vi.d. potassii  iodidtan  are  indicated.  Prof.  Da 
Costa  alternates /(3/a.f5zz  bromidtan  with  opium,  especially  in  children. 
Ergota  in  the  early  stages  would  seem  to  be  indicated,  but  in  prac- 
iice  it  is  of  little  or  no  value.  For  the  convulsions  or  spasms  that 
are  so  often  present  no  remedy  is  comparable  with  chloral,  gr.  xxx 
(2  Gm.),  repeated  as  indicated. 

Caution  in  the  use  of  the  coal-tar  products  must  be  exercised,  as 
the  relief  of  pain  and  spasm  may  be  the  onset  of  the  stage  of  collapse 
instead  of  the  beneficial  effects  of  these  drugs. 

Locally,  cold  compresses  to  the  head  and  spine  is  a  most  valuable 
measure,  continued  for  hours  at  a  time. 


38  PRACTICE    OF    MEDICINE. 

For  sequelce,  potassii  iodiduvi,  a  couise  of  hydrargyrttm,  oleum 
niorrhucr,  and  flying  blisters  along  the  spinal  column,  or  touching  the 
back  of  the  neck  with  the  Paquelin  cautery. 


RELAPSING  FEVER. 

Synonyms.  Febris  recurrens;  famine  fever;  bilious  typhoid 
fever;  spirillimi  fever. 

Definition.  An  acute  infectious,  contagious,  epidemic,  febrile 
disease,  self  limited,  characterized  by  a  febrile  paroxysm,  lasting 
about  six  days,  succeeded  by  an  entire  intermission  of  the  same  dura- 
tion, which  is  in  turn  followed  by  a  relapse  similar  to  the  first  seizure. 
Associated  with  alterations  in  the  viscera,  and  by  the  presence  in  the 
blood  of  a  specific  micro-organism — the  spirillum  of  Obermeyer.  No 
specific  lesion. 

Cause.  A  specific  poison;  contagions;  acquiring  the  greater 
activity  the  more  filthy,  crowded,  and  unhealthy  the  population  amid 
which  it  prevails. 

Pathological  Anatomy.  During  the  febrile  paroxysm  only,  the 
blood  contains  minute  corkscrew-shaped  organisms  or  spiral  fila- 
ments.— spirilli,  constantly  twisting  and  rotating, — the  spirillum  Ober- 
mcicri.  The  spleen  is  enlarged  and  usually  covered  with  a  fresh 
fibrinous  exudation.  The  capsules  present  a  mottled  appearance. 
The  splenic  pulp  is  more  or  less  softened  and  swollen  and  shows  en- 
larged Malpighian  bodies.  The  liver  and  kidneys  are  swollen  and 
congested. 

Symptoms.  No  prodromes.  Onset  abrupt,  with  fever,  102"- 
104°;  frequent,  rather  weak  pulse,  headache,  nausea,  vomiting,  and 
lancinating /a/«5  in  limbs  and  muscles,  marked  in  the  calf  of  the  leg  ; 
second  day,  feeling  o{  fullness  and  pressure  in  right  and  left  hypo- 
chondrium,  due  to  swollen  liver  and  spleen  ;  yawwi^/r*?  is  frequent ; 
seventh  day  fever  ends  by  crisis ;  fourteenth  day  symptoms  return  in 
milder  form,  continuing  about  four  days,  when  enters  slow  convales- 
cence, much  emaciated.     A'o  eruption.     Several  relapses  may  occur. 

Diagnosis.  Yellow  fever  has  many  points  of  resemblance,  but 
has  a  shorter  febrile  stage,  remission  not  so  complete,  vomiting  late 
and  characteristic,  normal  spleen,  and  the  late  appearance  of  yellow 
color. 


FEVERS.  39 

Re mii ten t fever  hegins  with  a  decided  chill,  followed  by  fever  and 
sweats,  and  not  the  progressive  rise  of  temperature  until  the  fifth  or 
seventh  day. 

Prognosis.  Recovery  the  rule,  but  protracted,  and  decided 
emaciatio7i  results. 

Treatment.  Expectant.  Act  on  the  secretions;  nourish  patient 
and  meet  urgent  symptoms.  For  fever,  antipyretic  doses  of  quinince 
sulphas  which,  however,  has  no  power  to  prevent  the  relapses  ;  for 
pain,  hypodermic  injections  of  viorphincB  sulphas  ;  for  nausea  and 
vomiting,  acidinn  carbolictmi  or  cerii  oxalas  ;  during  remission,  fer- 
rum  and  quinmcs  sulphas  in  tonic  doses. 


PERIODICAL  FEVERS. 

These  affections  are  characterized  by  the  distinct  periodicity  of  the 
phenomena,  having  intervals  during  which  the  patient  is  wholly  or 
nearly  free  frotti  fever. 


INTERMITTENT  FEVER. 

Synonyins.  Ague  ;  chills  and  fever ;  malarial  fever ;  swamp  fever. 

Definition.  A  paroxysmal  fever,  the  phenomena  observing  a 
regular  succession  ;  characterized  by  a  cold,  a  hot,  and  a  sweating 
stage,  followed  by  an  interval  of  complete  intertntssion  or  apyrexia, 
varying  in  length  according  to  the  variety  of  the  attack,  and  the 
presence  in  the  blood  of  a  protozoon,  known  as  the  Plasmodium 
malaricB. 

Cause.  The  presence  in  the  blood  of  a  specific  vegetable  micro- 
organism. Klebs  and  Tommasi-Crudeli  claim  to  have  isolated  a 
germ  —  Bacillus  7nalari(E  —  from  the  low-lying  atmosphere  over 
marshes  and  from  the  soil,  which  produced  a  malarial  paroxysm  with 
enlarged  spleen  in  an  inoculated  rabbit. 

Laveran  discovered  a  germ  in  the  human  blood  of  patients  suffer- 
ing from  malarial  fevers  which  is  now  known  as  the  hceinatozoa  of 
Laveran,  and  which  has  since  been  found  always  present  in  malarial 
attacks.  These  germs  are  true  parasites  and  exhibit  several  varieties 
of  form  and  size,  and  it  is  possible  that  there  may  be  several  species 


40  PRACTICE    OF    MEDICINE. 

which  are  capable  of  causing  the  distinct  types  of  the  disease,  as  ter- 
tian, quartan,  intermittent,  or  remittent. 

Laveran  describes  tlie  chief  forms  of  the  haematozoa  as  consisting 
of  amoeboid  spherical  bodies  wiih  nuclei;  crescentic  shapes  with 
nuclei :  rosettes  ;  ^wA  flagellate  bodies.  Laveran  considers  the  para- 
sites as  a  single  but  polymorphic  organism,  and  a  particular  form  of 
the  germ  is  peculiar  to  a  particular  type  of  the  disease.  Osier,  who 
has  devoted  much  time  to  the  study  of  the  subject,  "believes  that 
different  forms  of  the  germ  belong  to  distinct  species,  and  that  they 
are  not  all  different  stages  in  the  development  of  one  microbe." 

The  period  of  incubation  varies  from  a  few  days  to  weeks,  months, 
or  even  years,  an  auxiliary  condition,  such  as  exposure  to  cold,  over- 
exertion, excesses  in  eating  and  drinking,  or  great  excitement,  often 
being  necessary  to  give  efficiency  to  the  special  cause. 

Either  sex  and  all  ages  are  susceptible  to  the  poison. 

The  mode  of  infection  is  not  positively  understood.  It  often  enters 
the  system  in  the  inspired  air,  and  no  doubt  also  in  contaminated 
drinking-water  or  other  fluids. 

Pathological  Anatomy.  Blood  dark,  from  the  formation  of 
pigment  {Melanceinia).  Spleen  engorged  and  swollen  {Ague  cake). 
Liver  swollen  and  engorged  during  paroxysm. 

"Varieties.  Quotidian  when  a  daily  paroxysm  ;  tertian  when 
every  other  day  ;  quartan  when  it  occurs  first  and  fourth  days ;  octati 
when  weekly ;  duplicated  quotidian  when  two  paroxysms  daily ; 
duplicated  tertian,  two  every  second  day ;  double  tertian,  daily 
paroxysm,  but  more  severe  every  second  day.  Dumb  ague,  or 
masked  ague,  presents  irregularity  of  the  characteristic  phenomena. 

Symptoms.  Each  paroxysm  has  three  stages — the  cold,  hot,  and 
sweating. 

Cold  stage  begins  with  prodromes,  lassitude,  yawning,  headache, 
and  nausea,  followed  by  a  chill ;  the  teeth  chatter,  skin  pale,  nails 
and  lips  blue,  the  surface  rough  and  pale,  the  so-called  goose-skin, 
or  ctitis  anscrina,  nausea,  and  great  thirst,  while  the  thermometer  in 
the  axilla  or  mouth  shows  a  decided  rise  of  ietnperatitre,  I02°-I04°  F. ; 
these  phenomena  continuing  from  one  half  to  an  hour. 

Hot  stage  begins  gradually,  the  shivering  ceases,  the  surface  be- 
comes hot  and  flushed,  the  temperature  rising  to  io6°  F.  or  more, 
pulse  full,  headache,  nausea,  intense  thirst,  dry,  flushed,  swollen  skin. 


FEVERS.  41 

scanty  urine,  and  other  phenomena  o{  pyrexia,  continuing  from  one 
to  eight  or  ten  hours. 

Sweating  stage  begins  gradually,  first  appearing  on  Xht forehead, 
then  spreading  over  the  entire  surface;  the  fever  lessens,  the  tem- 
perature rapidly  falling  to  99°  or  98°,  pulse  less  full,  headache  lessens, 
and  a  general  feeling  of  comfort  exists,  sleep  often  following;  dura- 
tion of  the  sweating  from  one  to  four  hours,  when  the  intermission 
occurs,  the  patient  apparently  well,  except  for  a  feeling  of  general 
debility. 

The  occurrence  of  the  next  paroxysm  depends  upon  the  variety  of 
the  attack. 

The  paroxysm  may  be  ushered  in  by  a  decided  pain  in  one  or 
more  nerves,  instead  of  the  cold  stage,  to  wit :  "  brow  ague." 

Diagnosis.  No  difficulty  when  the  characteristic  chill,  fever,  and 
sweats  occur  and  enlarged  spleen,  and  the  presence  of  the  organism 
in  the  blood. 

Hectic  fever.  Distinguished  by  its  irregularity,  and  occurring 
secondary  to  an  organic  disease  ;  spleen  usually  normal  size,  and 
absence  of  the  organism  in  the  blood. 

PycEmia  produced  by  other  causes  than  malaria. 

Nervous  chills  show  an  absence  of  the  temperature  rise. 

Prognosis.  Recovery  the  rule.  Without  treatment  many  cases 
end  favorably  after  several  paroxysms,  others  passing  into  the  chronic 
form,  or  malarial  cachexice. 

Treatment.  Cold  stage  can  be  averted  and  the  other  stages 
greatly  modified  by  a  hypodermic  injection  of  either  morphines 
sulphas,  gr.  y%-)i  (0.008-0.016  Gm.),  or  pilocarpines  hydrochloras, 
gr.  y%  (0.008  Gm.),  or  chloroformi  spts.,  fjj  (4  Cc),  by  the  stomach. 
Hot  stage,  cool  drinks  and  cold  sponging.  Sweating  stage  :  when  ex- 
cessive, sponging  with  alumen  and  hot  water. 

Intermission  :  at  once  a  brisk  purgative,  followed  by  cinchona  in 
some  form,  the  most  efScient  being  quinines  sulphas,  gr.  xvj-xxiv 
(1-1.6  Gm),  in  solution  or  freshly  made  pills,  in  one  or  two  doses, 
three  \o  five  hours  before  the  expected  paroxysm.  Many  substitutes 
are  lauded  to  replace  the  salts  of  cinchona  bark,  but  without  a  doubt 
quinina  is  a  specific  in  the  strictest  sense  of  the  term. 

Free  action  on  the  bowels  is  essential  to  success,  a  good  combina- 
tion being  hydrargyri  chloridi  mitis,  sodii  bicarb.,  aa  gr.  v  (0.32 
Gm.),  followed  by  an  active  saline. 


42  PRACTICE    OF    MEDICINE. 

After  the  paroxysms  are  broken  up  use  liquor  potmsii  arseniiis, 
n\,v-x  (0.3-0.6  Cc),  for  a  long  time,  or  tincl.  ferri  chloridi,  n\,xx 
(1.3  Cc),  every  four  hours  or  a  combination  like  the  following: 

li .      Ferri  rcducti, 

Quiniiix  suljih., 3Agr.  Ix  4.         Cm. 

Acidi  arsenosi, gr.  j  .065  Gm. 

01.  pip.  nigr., rt\^xv  I.         Cc.  M. 

Ft.  pil.  No.  XXX. 

SiG. — One  pill  after  meals,  continued  for  one  month  or  longer. 

Relapses  being  common,  quinince  suIpJias  should  be  given  on  the 
second  or  third  day,  fourth  to  the  sixth,  twelfth  to  the  fourteenth, 
and  nineteenth  to  the  twenty-first  days. 

If  the  spleen  be  enlarged, — and  it  usually  is  in  long-continued  cases 
or  those  becoming  chronic  (marked  anaemia,  gastric  distress,  consti- 
pation with  depression  of  spirits  associated  with  headache  coming  in 
paroxysms  are  the  prominent  symptoms  of  the  cachexia), — use  locally 
ung.  hydrargyri  iodidi  rubri,  and  internally  ergota,  or  ergotine  (aq. 
ext.),  hypodermically  over  the  splenic  region,  and  tonic  doses  of 
quinina,  ferrum,  and  arsenicum. 


REMITTENT  FEVER. 

Synonyms.  Bilious  fever  ;  bilious  remittent  fever ;  marsh  fever; 
typhomalarial  fever. 

Definition.  A  paroxysmal  fever,  with  exacerbations  and  remis- 
sions, but  in  which  the  temperature  is  constantly  above  the  normal; 
characterized  by  a  moderate  cold  stage  (which  does  not  recur  with 
each  paroxysm) ;  an  intense  hot  stage,  with  violent  head-ache  and 
gastric  irritability  ;  and  an  almost  imperceptible  sweating  stage,  which 
is  frequently  wanting. 

Cause.  The  presence  in  the  blood  of  a  specific  vegetable  micro- 
organism, either  the  Bacillus  malaria  (Klebs  and  Tommasi  Crudeli), 
or  the  hcEinatozoa  of  Laveran  {inde  Intermittent  Fever). 

Pathological  Anatomy.  Blood  dark  {Melanamiu) ;  spleen 
enlarged,  soft,  filled  with  blood,  and  of  an  olive  color  ;  liver  congested 
and  swollen,  and  of  a  bronze  hue;  the  brain  hyperasmic  and  olive- 
colored  ;  gastro-intestinal  canal  markedly  hypera:inic. 

Symptoms.     Cold  stage  :  moderate  chill,  the  temperature  rising 


FEVERS.  43 

one  or  two  degrees,  coated,  dry  tongue,  oppression  at  the  epigasirium, 
slight  headache,  and  pains  throughout  the  body. 

Hot  stage  :  persistent  vomiting,  furred  tongue,  full  pulse,  rising  to 
loo  or  I20,  flushed  face,  injected  eye,  violent  headache,  paifis  in  limbs 
and  loins,  hurried  respiration,  the  temperature  rising  to  104°  F.,  or 
106°.  The  bowels  costive,  stools  tarry  and  offensive,  the  urine  scanty, 
high  colored  and  ureaic,  and  the  surface  becoming  yellowish.  Deli- 
rium occurs  when  the  temperature  is  very  high. 

Sweating  stage  :  after  six  to  twenty-four  hours  the  above  symptoms 
abate  and  slight  sweating  occurs,  the  pulse,  headache,  and  vomiting 
subside,  and  the  temperature  falls  to  100°  F.,  or  99°  F. 

This  is  the  remission,  during  which  the  symptoms  of  a  mild  pyrexia 
are  present. 

After  some  two  to  eight  or  twelve  hours  the  symptoms  of  the  hot 
stage  return,  generally  mifitis  the  chill,  and  this  is  termed  the 
exacerbatio7t,  which  is  in  turn  again  followed  by  the  remission. 

Duration.  From  seven  to  fourteen  days  the  average.  Fre- 
quently the  fever  ceases  to  remit,  and  instead  becomes  continuotis, 
the  symptoms  resembling,  if  they  are  not  identical  with,  the  typhoid 
state,  whence  the  term  typho-malarial fever,  or  malario-typhoid fever. 

Sequelae.  The  malarial  cachexia  results  when  the  poison  has 
not  been  eliminated  from  the  system. 

Persistent  headache  and  vertigo  are  the  results  of  the  intense 
meningeal  hyperaemia  that  sometimes  occurs. 

Diagnosis.  In  intermittent  fever  each  paroxysm  begins  with  a 
chill,  while  the  chill  seldom  recurs  in  remittent  fever;  a  distinct 
interinission  follows  each  paroxysm  of  the  intermittent  form,  while  a 
remission  occurs  in  remittent,  the  thermometer  showing  that  the  fever 
does  not  wholly  disappear ;  during  iheinterinissionihe  patient  is  appa- 
rently well ;  such  is  not  the  case  in  the  remission  of  intermittent  fever. 

Typhoid  Fever  is  mistaken  for  remittent  fever,  but  the  absence  of 
the  characteristic  temperature  record,  diarrhoea,  eruption,  tympanites, 
deafness,  severe  prostration,  and  the  Widal  reaction,  with  the  pres- 
ence in  blood  of  the  malarial  organism,  should  prevent  such  an  error, 
as  a  diagnosis  can  always  be  made  with  absolute  certainty  by  an 
examination  of  the  blood. 

Prognosis.     Uncomplicated  cases  are  favorable. 

Treatment.  Qtdnincs  sulphas,  gr.  xvj-xx  (1-1.3  Gm.)  per  diem, 
is  the  remedy.     Better  administered  during  the  remission,  if  possible. 


44  PRACTICE    OF    MEDICINE. 

If  an  irritable  stomach  prevents  its  administration  by  the  mouth, 
use  it  by  the  hypodermic  method  or  in  a  suppository.  During  the  hoi 
stance,  cool  sponging,  cold  to  the  head,  and  if  a  tendency  to  cerebral 
congestion,  dry  or  wet  cups  to  the  nape  of  the  neck  and — 

B-     Tinct.  aconit.  rad., r\\]  .12  Cc. 

I-iq.  potassii  citrat. , f^^jij  8.       Cc. 

Liq.  ammon.  acetat., fjij  8.      Cc.  M. 

Every  two  hours. 

During  the  remission  relieve  the  intestinal  canal  with — 

R.      Hydrargyri  chlor.  mitis,    .    .    .    .  gr.  v  .3    Gm. 

Sodii  bicarb. , gr-  v  .3    Gm. 

Pulv.  ipecac, gr-  ss  .03  Gm.  M. 

In  pulv.  p.  r.  n. 

The  same  precautions  are  essential  after  the  paro.xysms  are  broken 
up  to  prevent  their  return  on  the  septenary  periods  that  were  recom- 
mended for  intermittent  fever. 

It  is  but  fair  to  mention  the  statement  of  Koch,  seconded  by  Hare, 
that  quinina  is  a  nephritic  irritant,  but  if  so,  it  must  be  in  toxic 
amounts,  which  are  not  recommended. 

For  convalescence :  Ferrum,  arsenicu»i,  and  slrychnina  are  indi- 
cated. 


PERNICIOUS  MALARIAL  FEVER. 

Synonyms.  Congestive  fever;  malignant  intermittent  fever; 
malignant  remittent  fever;  the  congestive  chill. 

Definition.  A  malignant,  destructive  malarial  fever,  which  may 
be  of  the  intermittent  or  remittent  form;  characterized  by  intense 
congestion  of  one  or  more  internal  organs,  together  v/ith  dangerous 
perversion  of  the  functions  of  innervation. 

Cause.  A  high  degree  of  malarial  poison.  i^Vide  Intermittent 
Fever.) 

Varieties.  Gastro-enteric ;  thoracic ;  cerebral ;  hemorrhagic  ; 
algid. 

Symptoms,  Any  of  these  varieties  may  begin  either  as  an  inter- 
mittent or  remittent  fever;  again,  y}n&  first  paroxysm  is  rarely  per- 
nicious, but  appears  as  the  ordinary  malarial  attack. 


FEVERS.  45 

TYiQ  gastro-entericv3.x\€iy  has,  as  distinctive  features,  intettse  jiausea 
and  vojiiitijig,  purging  of  thin  discharges  mixed  with  blood,  tenesmus, 
burtiing  heat  in  stomach,  intense  thirst,  frequent,  weak  ^iilse,  face, 
hands,  and  feet  cold,  with  shrunken  features,  and  an  intense  depres- 
sion of  all  the  vital  forces.  This  condition  continues  from  half  an 
hour  to  several  hours,  when  either  an  inter-  or  a  remission  occurs. 

Thoracic  variety  often  combined  with  the  one  just  described.  Its 
characteristic  features  are  due  to  overwhelming  congestion  of  the 
lungs,  such  as  violent  dyspncea,  gasping  for  air,  fifty  to  sixty  respira- 
tions per  minute,  oppressed  cough  with  shght  amount  of  blood-streaked 
ST^vX^.,  frequent,  weak  pulse,  cold  surface,  and  terror-stricken  features. 
Duration  same  as  the  above. 

Cerebral  vaxitty,  due  to  intense  congestion  of  the  brain  ;  sometimes 
effusion  of  serum  into  the  ventricles,  or  even  rupture  of  small  blood- 
vessels. Characterized  by  violefit  delirium,  followed  by  stiipor  and 
coma,  slow,  full  pulse,  the  surface  e.iih.e.r  flushed  or  livid.  Cases  may 
either  resemble  apoplexy — comatose  variety — or  acute  meningitis — 
delirious  variety.     Duration  same  as  the  other  forms. 

Hemorrhagic  variety,  or  the  yellow  disease,  as  it  has  been  termed, 
begins  as  an  ordinary  inter-  or  remittent  fever,  soon  followed  by  signs 
of  internal  congestion,  to  wit :  nausea,  voiniting,  dyspnoea,  severe 
paitis  over  liver  and  kidney,  continuing  for  a  few  hours,  when  the 
surface  suddenly  turns  yellow  and  bloody  urine  is  voided,  after  which 
an  inter-  or  a  remission  and  marked  abatement  occur,  to  be  sooner  or 
later  followed  by  a  second  paroxysm,  which  is  more  severe,  with  signs 
of  cerebral  congestion.  Blood  may  also  escape  from  other  parts  than 
the  kidneys. 

Algid  variety  is  characterized  by  intense  coldness  of  the  surface, 
while  the  rectal  temperature  ranges  from  104°  to  107°  F.  The  attack 
begins  with  a  chill,  which  is  soon  followed  by  fever  of  variable  dura- 
tion, when  the  body  becomes  cold,  the  axillary  temperature  falling  to 
90°,  88°,  or  even  85°  F.,  a  cold  sweat  covers  the  surface,  the  tongue 
is  white,  moist,  and  cold,  the  breath  is  icy,  the  voice  feeble  and 
indistinct,  the  pulse  slow,  feeble,  and  often  absetit  at  the  wrist,  and 
with  all  these  symptoms,  the  patient  complains  of  a  sensation  of 
burning  and  intense  thirst.  The  mind  is  clear,  but  the  countenance 
is  death-like. 

Duration,     Pernicious  malarial  fever,  in  any  of  its  forms,  may 


40  PRACTICE   OF    MEDICINE. 

continue  from  a  few  hours  until  one,  two,  or  three  days.     Recovery 
is  rare  after  a  second,  almost  never  after  a  third,  paroxysm. 

Diagnosis.  A  positive  diagnosis  can  always  be  made  by  an 
examination  of  the  blood. 

Yellow  fever  is  most  apt  to  be  confounded  with  the  hemorrhagic 
variety,  and  as  they  both  occur  in  the  same  localities,  the  diagnosis 
is  difficult ;  the  early  yellozuness  of  the  surface,  with  hamaturia  and 
the  absence  of  the  black  vomit  and  epidemic  prevalence,  are  the 
chief  points  of  distinction. 

The  cerebral  variety  may  be  mistaken  for  cerebral  apoplexy,  vten- 
itigitis,  and  lercrmic  convulsions.  Nor  is  it  always  an  easy  matter  to 
differentiate  between  these  conditions. 

The  ^(^astro-enteric  variety  may  be  mistaken  for  the  early  stage  and 
the  al^i^'-id  variety  for  the  later  stage  of  cholera,  but  the  epidemic 
prevalence  of  the  latter  should  be  of  material  aid  in  determining  the 
diagnosis. 

Prognosis.  In  all  varieties  the  result  is  unfavorable,  unless  it 
can  be  controlled  prior  to  the  second  paroxysm.  Cases  in  which  an 
intermission  occurs  are  better  controlled  than  where  a  remission 
follows.     The  mortality  is  one  in  eight  from  all  plans  of  treatment. 

Treatment.  The  first  indication  in  all  varieties  is  to  bring  about 
reaction.  In  the  cold  stage,  heat  to  the  surface,  and  stimulating 
lotions ;  in  the  hot  stage,  cold  to  the  surface  and  the  hypodermic  injec- 
tion oi  morphincz  sulphas,  gr.  ^  (0.016  Gm.),  at  once.  After  reaction, 
qidnincB  stilphas,  not  less  than  gr.  xl  (2.6  Gm.),  repeated  p.  r.  n.; 
administer  by  stomach,  rectum,  or,  better  still,  by  hypodermic  injec- 
tion. Dr.  Bartholow  pronounces  the  following  one  of  the  best  formulae 
for  the  hypodermic  use  of  quinina  : 

R.     Quininre  disulph., gr.  1  3.3    Gm. 

Acid,  sulph.  dil., n\,c  6.15CC. 

Aqua;  font., f3J  30.       Co. 

Acid,  carbol.  liq., TT\,v  .3    Cc.  M, 

The  new  salt,  qiiini7ta  bimuriatica  carbamidata,  is  highly  recom- 
mended for  hypodermic  use,  being  very  soluble. 

The  following  formula,  known  as  "  Warburg's  Tincture,"  has 
during  the  last  few  years  gained  considerable  reputation  in  the 
various  forms  of  malarial  fevers  ; 


FEVERS.  4? 

R  .     Rad.  rhei,  P.  aloe  soc. ,  and  Rad. 

angelica  officinalis,     ...     az.    "^'iy  120.  Cc. 

Rad.    helenii,    Crocus  Hipsan., 

Sem.  foeniculi,  and  Creta  prae- 

parat.,       aa    ^ij  60.  Cc. 

Rad.    gentian,    Rad.    zedoar,    P. 

cubeb,  G.  myrrh,  G.  camphor, 

and  Boletus  Laricis,    ...     aa    ,^j  30.  Cc. 

Confect.   damocratis,* 5iv  120.  Cc. 

Quininas  sulph. , 5  Ixxxij  2460.  Gm. 

Spts.  vini  rect., Oxx  600.  Cc. 

Aquce  purse, Oxij  360.  Cc.  M. 

Macerate  in  a  water  bath  twelve  hours,  express,  and  filter. 

Each  half  ounce  (15  Cc.)  contains  quininse  sulphas,  gr.  viiss 
(0.46  Gm.).  If  the  stomach  is  too  irrhable  to  retain  the  tincture,  the 
tincture  may  be  evaporated  to  dryness  and  administered  in  capsules, 
each  containing  the  equivalent  of  either  one  or  two  drachms. 

For  'Ca.Q  gastro-enteric  variety.  Prof.  Da  Costa  suggests  : 

R.     Morph.  sulph., ^-  %  -016  Gm. 

Pulv.  camph., gr.  j  .065  Gm. 

Mass.  hydrarg. , gf- jj  -12    Gm. 

Pulv.  capsici, gr-  ss  .03     Gm.         M. 

In  pills  every  half  hour  until  the  character  of  the  stool  is  changed. 

For  the  thoracic  variety,  dry  or  wet  cups  and  ammonii  carbonas, 


*  Formula  of  Confectio  damocratis  : 

Cinnamon, 14.    Gm. 

Myrrh, 11.    Gm. 

White  agaric,  Spikenard,  Ginger,  Spanish  saf- 
fron, Treacle,  Mustard  seed.  Frankincense, 
and  Chian  Turpentine, aa     10.    Gm. 

Camel's  hay,  Costus  arabacus,  Zeodary,  Indian 
leaf,  Mace,  French  lavender,  Long  pepper. 
Seeds  of  harwort,  Juice  of  rape  cistus, 
Strained  storax,  Opponex,  Strained  galba- 
num.  Balsam  of  Gilead,  Oil  of  nutmeg,  Rus- 
sian castor, aa       8.    Gm. 

Water  germunder,  Balsam  tree  fruit,  Cubeb, 
White  pepper,  Seeds  of  carrot  of  Crete,  Foley 
mont.  Strained  bdellium, aa        7.    Gm. 

Gentian  root,  Celtic  hard.  Leaves  of  Dittany  of 
Crete,  Red  rose,  Seeds  of  Macedoniuni,  Parsley, 
Sweet-fennel  seeds,  Seeds  of  lesser  cardamon, 
Gum  arable.  Opium, aa       5.    Gm. 

Sweet  flag,  Wild  valerian,  Anise  seed,  Saga- 
pernum, aa       3.    Gm. 

Spigrul,  St.  John's  wort.  Juice  of  acacia.  Cate- 
chu, Dried  bellies  of  skunk, aa       2.5  Gm. 

Clarified  honey,        915.    Gm. 

The  roots  to  be  finely  powdered  and  the  whole  mixed  thoroughly. 


48  PRACTICE    OK    MEDICINE. 

spiritits  avimonia  atomaticus,  caffeina  citrata,  and  hypodermic  injec- 
tions of  strychnin CE  sulphas. 

For  the  cerebral  variety,  venesection,  or  cups  or  leeches  to  the 
neck,  cold  to  the  head,  prompt  purgation,  and  free  action  on  the 
kidneys  and  skin. 

For  the  ali^id  variety,  ivartnth  to  the  surface,  hypodermic  use  of 
morpliina:  sulphas  and  atropina:,  and  the  free  use  of  a»inionii  car- 
bonas  and  alcoholic  siiviulants. 

For  the  hemorrhagic  variety,  purgatives,  viorphincE  sulphas  hypo- 
dermically,  and  either  aciduvi  suiphuricuvi  dil.,  acidum  gallic, 
MonseVs  solution,  or  terebinthina. 

The  following  is  highly  spoken  of  for  hemorrhages  : 

R..     Ext.  ergotDefld., f  .^  ss  IS-  Cc. 

Acid,  sulph.  dil., f^'ss  6.  Cc. 

Acid,  gallic, c^j  4.  Gm. 

Syr.  zingib., •     .    .    .  f  3  iij  12.  Cc. 

Aquae q.  s.  ad  f^iij         ad         90.  Cc. 

SiG. — Dessertspoonful  every  four  hours,  well  diluted. 

After  the  paroxysms  are  controlled,  a  long  course  oi  ferrwn  and 
arsenicuvi,  with  quinitia  on  the  septenary  days. 


YELLOW  FEVER. 

Synonyms.  Yellow  Jack;  bilious  malignant  fever ;  typhus  icter- 
ode  ;  Mediterranean  fever  ;  sailor's  fever  ;  black  vomit. 

Definition.  An  acute,  infectious,  paroxysmal  disease,  of  three 
stages — \.\\G  febrile,  the  remission,  and  the  collapse  ;  characterized  by 
violent  fever,  yellowness  of  the  surface,  and  "  black  or  coffee-ground 
vomit."  Tendency  fatal ;  one  attack  confers  immunity  from  a  sec- 
ond.    Not  contagious. 

Cause.  A  specific  poison,  existing  only  with  a  high  temperature 
and  destroyed  by  frost.  Not  due  to  the  malarial  poison.  Usually 
seen  during  the  months  of  June,  July,  August,  and  September. 

The  true  home  of  yellow  fever  is  in  the  tropics. 

Guiteras  mentions  three  areas  of  infection  :  i.  The  focal  zone  in 
which  the  disease  is  never  absent,  including  Havana,  Vera  Cruz,  Rio, 
and  other  Spanish-American  ports.  2.  Peri-focal  zone  or  regions  of 
periodic  epidemics,  including  the  ports  of  the  tropical  Atlantic  in 


FEVERS.  49 

America  and  Africa.     3.  The  zone  of  accidental  epidemics,  between 
the  parallels  of  45°  north  and  35°  south  latitude. 

Epidemics  are  due  to  the  introduction  of  the  specific  germ,  either 
from  patients  affected  with  the  disease  or  through  infected  articles. 

Neither  age,  sex,  race,  nor  social  condition  has  immunity.  One 
attack  protects  the  individual. 

Pathological  Anatomy.  Ski7i  lemon  or  greenish-yellow  color, 
due  to  dissolution  of  the  red  blood  corpuscles ;  heart  softened  by 
granular  degeneration  ;  stomach,  veins  deeply  engorged,  the  mucous 
membrane  softened,  and  containing  more  or  less  "coffee-ground" 
matter,  which  consists  of  blood  corpuscles  deprived  of  their  haemo- 
globin, white  corpuscles,  epithelial  cells,  and  debris.  Intestines  much 
the  same  as  the  stomach  ;  liver,  yellow  color  and  a  fatty  degeneration 
of  the  hepatic  cells  ;  kidtteys,  granular  degeneration  of  the  epithelium 
of  the  tubules.  The  spleen  presents  a  singular  lack  of  pathological 
change. 

Symptoms.  The  hicubation  lasts  from  twenty-four  hours  to  six 
and  exceptionally  ten  days.  The  more  severe  the  epidemic,  the 
shorter  the  period  of  incubation. 

First  stage,  the  febrile,  beginning  either  with  the  prodromes  of 
malaise,  headache,  and  anorexia,  or  suddenly  with  a  chill,  high/ever, 
in  a  few  hours  reaching  104°  to  106°  F.,  rapid  pulse,  90-100  beats, 
brilliant  eye,  flushed  countenance,  coated  tongue,  irritability  of  the 
stomach,  and  severe  neuralgic  pains  m  the  head,  limbs,  epigastrium, 
back,  and  large  joints.  The  patients  are  restless  and  anxious,  with 
a  feeling  of  general  prostration.  In  severe  attacks  deliriuju  is  fre- 
quent. The  urine  is  scanty,  acid,  high  colored,  and  contains  albu- 
min. A  peculiar  and  characteristic  odor  is  emitted  from  the  patient. 
Duration  of  the  first  stage  from  thirty-six  hours  to  three  or  four  days. 

Second  stage,  the  remission,  when  the  temperature  declines  to  100° 
or  99°  F.,  and  all  the  distressing  symptoms  abate  or  subside,  and 
with  some  critical  evacuation  convalescence  occurs,  or,  more  com- 
monly, after  from  a  few  hours  to  one  to  four  days,  the — 

Third  stage,  the  stage  of  collapse,  or  the  period  of  secondary  fever, 
is  ushered  in  by  a  return  of  all  the  symptoms  of  the  first  stage  in  an 
exaggerated  form,  followed  by  yellowness  of  the  skin,  passing  to  a 
deep  mahogany  color,  black  vomit,  and  hemorrhages  from  other  parts, 
feeble  pulse,  cold  surface,  irregular  respiration,  and  death  from  ex- 
haustion, the  mind  remaining  clear  until  the  end. 
4 


50  PRACTICE    OF    MKDICINE. 

The  above  symptoms  represent  a  sthenic  case ;  other  varieties  are 

the  ali^d,  Ju-viorrhagic,  and  typhus. 

Duration.  Depends  upon  the  variety  ;  from  a  few  hours  to  a  few 
days.     Rarely  continues  longer  than  one  week. 

Diagnosis.  Pernicious  fever,  hemorrhagic  variety,  is  apt  to  be 
mistaken  for  yellow  fever.  Yellow  fever  is  a  disease  oi  one  paroxysm 
and  one  remission,  epidemic,  with  albuminuria  and  black  vomit. 
Pernicious  fever  has  more  than  one  paroxysm,  not  epidemic,  rarely 
black  vomit  or  albumin  in  urine.  A  valuable  diagnostic  point  from 
malarial  fevers  is  that  quinine  has  no  similar  influence  over  yellow 
fever. 

Prognosis.  One  in  four  perish.  Short  cases  unfavorable,  as  are 
the  hemorrhagic  and  algid  varieties. 

Treatment.  No  specific  :  a  "  self-limited  "  disease.  The  indica- 
tions are  to  keep  the  patient  quiet  in  bed,  and  to  treat  the  symptoms 
as  they  arise,  and  to  nourish  the  patient.  Good  nursing,  ventilation, 
early  emesis  and  purgation,  with  diaphoretics  and  diuretics,  are 
apparently  beneficial.  Large  doses  of  quinines  sulphas,  early  in  the 
attack,  for  high  temperature,  by  hypodermic  method.  For  the  irrita- 
ble stomach,  ice  slowly  dissolved  in  the  mouth,  and  acidum  carbolicum, 
gr.  %  (0.016  Gm.),  in  aqua  menthcE pip.,  every  two  hours,  alternated 
with  liquor  calcis  and  milk,  each  an  ounce  ;  or — 

R.      Hydrargyri  chlor.  mite,     ....     gr.  ^j  .005 

Morphinx- sulph., gr-  2V  •°°3  ^• 

Every  two  hours  until  nausea  is  controlled. 

Surgeon -General  Sternberg  suggests  the  following  toward  a  specific 
action  : 

R .     Sodii  bicarb. , gr.  cl  lo.       Gm. 

Hydrargyri  chloridi  corr.,      ...     gr.  ^  .02  Gm. 

Aqua;  destillat.,       Oij  950.       Cc.             M. 

SiG. — Three  tablespoonfuls  every  hour. 

For  the  black  vomit  and  hemorrhages,  either  liquor  ferri  subsul- 
phatis  or  plumbi  acetas.  The  pains,  restlessness,  or  delirium  are  best 
controlled  by  the  hypodermic  use  of  morphtjice  sulphas  or  atropine. 
Free  stimulation  from  the  onset  is  needful. 

When  an  epidemic  of  yellow  fever  breaks  out  all  persons  whose 
duty  does  not  keep  them  with  the  sick  should  leave  the  infected  dis- 


FEVERS.  51 

trict  at  once.  "  The  cardinal  principles  involved  in  prophylaxis  dur- 
ing an  epidemic  are  summed  up  in  the  oft-quoted  words,  '  Isolation, 
disinfection,  and  depopulation.'  " 


ERUPTIVE  FEVERS. 

As  a  group,  the  eruptive  or  exanthematous  fevers  have  many  feat- 
ures in  common.  All  have  a  period  of  incubation,  are  characterized 
by  a  fever  of  more  or  less  intensity  preceding  the  eruption,  by  an 
eruption  which  is  peculiar  to  each,  occurring  most  commonly  in 
childhood,  rarely  attacking  the  same  person  twice,  very  prone  to 
occasion  serious  sequelae,  and  are  contagious.  Their  origin  is  as  yet 
undetermined. 


SCARLET  FEVER. 

Synonym.  Scarlatina,  from  the  (old)  Italian  scarlattina,  scarlatto 
(red). 

Definition.  An  acute,  self-limited,  contagious,  i7ifectious  disease, 
usually  of  childhood  ;  characterized  by  high  temperature,  rapid  pulse, 
a  diffused  scarlet  eruption,  terminating  with  desquamation,  inflam- 
mation of  the  mouth  and  throat,  and  frequently  more  or  less  grave 
nervous  phenomena.  Serious  sequels  frequently  follow  an  attack. 
One  attack  confers  immunity  from  the  disease. 

Pathological  Anatomy.  An  acute  inflammation  of  the  skin, 
with  exudation — a  true  Dermatitis.  A  granular  change  in  all  the 
glandular  structures,  most  marked  in  the  Peyerian  glands,  although 
also  occurring  in  the  stomach  and  kidneys.  Streptococci  are  usually 
found  in  abundance  in  the  glands  and  areas  of  suppuration. 

Cause.  A  specific  poison,  maintaining  its  vitality  for  a  long  time. 
Highly  contagious,  the  contagion  residing  chiefly  in  the  desquamated 
epidermis.  Klebs'  micrococci,  the  "  monas  scarlatinosum,"  may 
prove  to  be  the  poison.     Incubation  short,  one  to  seven  days. 

"Varieties.  Scarlatina  simplex,  scarlatina  anginosa,  and  scar- 
latina 7naligna. 

Symptoms.  A  mild  attack  is  a  very  trivial  affection,  but  in  its 
severest  form  there  are  few  diseases  more  malignant. 

Onset  sudden  with  a  decided  chill ■a.vi^  vomitittg  (in  infants,  convul- 


52  PRACTICE    OF    MEDICINE. 

sions),  pain  in  the  throat  followed  by  high  fever,  soon  reaching  105°; 
a  rapid  pulse,  \  10  to  140,  being  frequent.  At  the  end  of  twenty-four 
hours  a  bright  scarlet  rash  appears  on  the  neck  and  chest,  spreading 
over  the  entire  body  within  a  few  hours;  the  eruption  is  not  raised, 
there  is  no  intervening  healthy  skin,  and  scattered  irregulaily  are 
points  of  a  darker  hue.  With  the  appearance  of  the  eruption  occurs 
burning  heat  of  surface,  pain  in  the  throat,  and  difficulty  in  deglu- 
tition, the  throat  on  inspection  presenting  the  appearance  of  a  catar- 
rhal inflammation.  Tongue  at  first  furred,  later  red,  with  prominent 
papilkc — the  "strawberry  tongue."  There  also  occurs  headache, 
great  restlessness,  and  in  severe  cases  delirium.  Diarrhaa  quite 
common. 

On  the  fourth  or  fifth  day  the  fever  declines  by  lysis,  the  eruption 
fading,  and  on  the  sixth  or  eighth  day  desquamation  begins,  con- 
tinuing for  ten  days,  two  weeks,  or  longer,  the  convalescence  being 
slow,  the  patient  emaciated  and  pale. 

Scarlatina  anginosa  are  cases  like  the  above  with  the  addition  of 
great  inflammation  and  swelling  o{\)l\^ pharynx,  nose,  palate,  tonsils, 
and  neighboring  glands,  the  swollen  glands  pressing  upon  the  sur- 
rounding parts,  causing  difficulty  of  breathing  and  of  deglutition. 
Frequently  the  enlarged  glands  suppurate,  increasing  the  constitu- 
tional symptoms  and  the  distress  of  the  patient. 

Scarlatina  jnaligna  are  cases  with  decided  nervous  phenomena,  to 
wit :  convulsions,  delirium,  and  muscular  twitching,  the  temperature 
reaching  107°  to  1 10°,  the  pulse  rapid,  feeble,  and  irregular,  the  erup- 
tion delayed,  of  a  purplish  color,  and  \n  patches. 

Complications.  Three  conditions  are  always  to  be  looked  for 
in  all  cases  of  scarlet  fever  ;  otitis,  affections  of  the  joitits,  and  acute 
nephritis,  each  adding  to  the  gravity  of  the  attack. 

The  association  o{  diphtheria  with  scarlet  fever  adds  to  the  severity 
of  the  attack.  The  engrafting  of  these  two  diseases  on  the  same 
individual  is  not  an  infrequent  occurrence. 

Sequelae.  Chronic  sore  throat;  conjunctivitis  ;  otorrhoea;  chronic 
diarrhoea  ;  subacute  rheumatism  ;  chorea  ;  endocarditis;  pericarditis; 
pleuritis;  acute  Bright's  disease,  and  cutaneous  dropsy. 

Diagnosis.  A  typical  case  should  cause  no  difficulty  ;  the  high 
fever,  rapid  pulse,  sore  throat,  and  early  scarlet  eruption,  followed  by 
desquamation,  should  leave  no  doubt. 

Measles :  the  above  symptoms  are  absent,  and  (ra/arr/^a/ symptoms 


FEVERS.  53 

present,  the  later  appearance  of  the  eruption  and  the  difference  in 
its  character. 

Small-pox  :  eruption  on  the  third  day  in  spots,  changing  to  pustules 
with  secondary  fever. 

Dengue  or  break-bone  fever  :  absence  of  the  above  typical  symp- 
toms, and  presence  of  stYtrQ  pains  in  the  bones. 

Diphtheria  :  gradual  invasion,  great  prostration,  and  no  eruption, 
but  the  frequent  complication  of  scarlatina  and  diphtheria  must  be 
remembered. 

Meni7igitis  may  be  suspected  from  the  symptoms  of  scarlatina 
maligna  ;  the  epidemic  influence,  eruption,  and  rapid  pulse  are  points 
of  difference. 

Prognosis.  Depends  upon  the  character  of  the  attack  and  the 
association  of  complications.  Acute  nephritis,  endo-  and  pericarditis, 
and  pleuritis  add  to  the  gravity.  The  prognosis  is  more  grave,  how- 
ever, from  the  association  of  diphtheria,  the  inflamed  naso-pharynx 
presenting  fertile  soil  for  the  ravages  of  that  grave  malady.  Never 
can  be  positive  of  the  result.  Mortality  ranges  from  ten  to  twenty- 
five  per  cent. 

Treatment.  As  with  other  eruptive  fevers,  so  with  scarlatina, 
there  are  no  specific  remedies  by  means  of  which  it  can  be  arrested 
or  controlled.  Symptomatic  treatment  judiciously  applied,  however, 
may  afford  relief  and  diminish  the  fatality. 

The  indications  are  for  rest  in  bed,  good  ventilation,  isolation,  dis- 
infection, cooling  drinks,  action  upon  the  skin,  and  light  nourishment. 

For  a  case  of  scarlatina  simplex  small  doses  of  hydrargyri  chloridi 
mite,  sodii  bicarbonatis,  and  ptilvis  ipecac,  every  two  or  three  hours 
until  thorough  movement  of  the  bowels  occurs,  will  favorably  influence 
the  fever  and  rapid  pulse  and  general  distress. 

For  cases  with  \i\^  fever  and  rapidity  of  pulse,  aconitum,  digitalis, 
quinincB  sulphas;  or,  antifebrin,  gr.  j-ij  (0.065-0.13  Gm.),  every  couple 
of  hours,  or  phenacetin,  gr.  j-ij  (0.065-0.13  Gm.),  every  two  or  three 
hours,  with  cool  sponging,  cold  bath,  douche,  or  pack.  When,  how- 
ever, the  temperature  reaches  102.5°,  ^-^  once  use  full  bath  at  90°  F., 
for  eight  to  ten  minutes,  then  dry  child  quickly,  wrap  in  blanket  and 
put  to  bed,  repeating  bath  if  temperature  and  nervous  phenomena 
are  marked. 

If  the  surface  be  pale,  the  circulation  feeble,  and  the  eruption  tardy 
in  appearing,  benefit  will  follow  the  administration  of  tinctura  digi- 


54  PRACTICE    OF    MEDICINE. 

talis  or  iinctura  belladonna,  n\,j-v  (0.06-0.3  Cc),  according  to  age, 
and  a  hot  bath  or  pack. 

With  the  appearance  of  the  eruption  anoint  the  entire  body,  save 
the  head,  with — 

B-     Eucalyptol fjj  4.  Cc. 

Ung.  petrolei, 3J  30.  Gm.  M. 

The  inunction  acts  beneficially  in  many  ways.  It  reduces  the  fever 
by  soothing  the  cutaneous  burning  and  irritation  ;  later  on,  when 
desquamation  occurs,  it  limits  the  source  of  further  infection  by  pre- 
ventingthe  diffusion  of  the  otherwise  dry  scales  in  the  air ;  and,  finally, 
it  protects  the  surface  from  the  influences  of  sudden  changes  of 
temperature,  thus  to  a  great  extent  avoiding  the  danger  of  nephritis. 

For  scarlatina  atiginosa,  the  internal  use  of  the  following  combina- 
tion is  valuable  as  a  blood  tonic  and  throat  astringent ; 

R.     Tinctunt  ferri  chlor. , f_:^ij  8.  Cc. 

Glycerini, f_^j  30.  Cc. 

AquK, ~   q.  s.  ad  f^ij         ad         60.  Cc.  M. 

SiG. — One-half  to  one  teaspoonful  every  two  hours,  undiluted,  according 
to  the  age. 

Externally,  ice  or  cold  compresses,  unless  they  cause  chilliness, 
if  so,  heat.  Astringent  gargles  and  small  pellets  of  ice  dissolved  in 
the  mouth  are  of  use.  The  throat  and  nasal  cavities  are  kept  clean 
and  the  breathing  relieved  by  the  use  of  Dobell's  solution  used  with 
a  hand  atomizer  every  hour.     The  formula  is : 

R.     Acid,  carbolici, f^iss  6.  Cc. 

Sodii  biboracis, 

Sodii  bicarb., ^  3'j  8.  Gm. 

Glycerini, f^ij  60.  Cc. 

Aquce,      q.  s.   ad    Oij  ad         950.  Cc.  M. 

The  use  of  this  solution  proves  grateful  to  the  patient,  relieving  the 
breathing  through  the  nose  by  loosening  the  tenacious  secretions.  An 
excellent  gargle  for  those  old  enough  to  properly  use  one  is : 

R.     Thymol, gr.  iv  .26  Gm. 

Glycerini f  ?j  30.       Cc. 

Aq.  dest. , f^j  30.      Cc.            M. 

SiG. — A  throat  wash.     If  necessary,  dilute  further. 


FEVERS.  55 

An  excellent  mouth  and  throat  cleanser  as  well  as  gargle  is  aqua 
hydrogenii  dioxidi,  full  strength  or  diluted. 

For  scarlatina  tnaligna,  in  addition  \.o  ferrum  and  quinines  sulphas, 
the  chief  reliance  must  be  on  alcoholic  stimulants,  guiding  the  amount 
by  their  effects.  In  children,  wine-whey,  milk-punch,  and  egg-nog 
are  eligible  for  the  administration  of  stimulants  and  nourishment. 

Convtilsions,  or  only  great  restlessness  and  muscular  twitchings,  are 
the  result  of  the  high  grade  of  fever,  and  call  for  prompt  treatment. 
Experience  in  such  cases  is  against  the  group  of  antipyretic  drugs, 
as  not  meeting  the  indication  promptly  enough.  The  cold  wet  pack 
or  the  cold  bath  with  cold  affusion  or  the  ice  cap  are  the  most  efficient 
and  rapid  means  of  reducing  the  temperature  and  relieving  the 
nervous  disturbances. 

Prof.  Da  Costa  advocates  the  administration  of  a^nmonii  carbonas, 
in  small  doses  at  frequent  intervals,  to  prevent  the  liability  of  heart- 
clot,  and  for  its  salutary  influence  over  the  disease. 

It  is  claimed  that  a  characteristic  micrococci  is  found  in  the  blood, 
and  that,  consequently,  the  disease  can  be  favorably  influenced  by 
acidum  carbolicum,  thy^nol,  or  acidum  boricum ;  an  eligible  way  of 
administering  acidum  carbolicum  is  the  syr.  a7mnonics  phenatis 
(Declat),  f^ss-j  (2-4  Cc),  four  to  six  times  daily. 
•  There  can  be  no  doubt  but  that  the  complications  and  sequelae 
attending  scarlet  fever  constitute  the  principal  dangers  of  the  dis- 
ease. 

If  diphtheria  develop,  the  combination  oi  ferrum  and  hydrargyri 
chloridum  corrosivum  with  free  alcoholic  stimulation  are  the  indica- 
tions. 

Acute  nephritis  is  so  commonly  associated  with,  or  follows  the 
decline  of  scarlatina  that  it  is  a  prudent  practice  to  examine  the 
urine  daily.  If  albumin  appear,  add  to  the  ferrum,  tiftctura  can- 
tharidis  in  minute  doses,  and  dropsy  and  urasmic  symptom.s  may  be 
prevented.  If,  however,  true  scarlatinal  nephritis  does  develop,  the 
following  mixture  of  Hughes-Bennett,  with  saline  purgatives  and 
either  a  hot  bath  or  the  hot-air  bath  twice  or  oftener  daily,  will  be 
followed  by  improvement : 

R .     Potassii  acetat. , .:^  ij  8.  Gm. 

Spts.  setheris  nitrosi, f.l^s  15.  Cc. 

Aquse, q.  s.  adf^ij          ad  60.  Cc.                 M. 

SiG. — Teaspoonful  every  two  hours,  well  diluted. 


56  PRACTICE    OF    MEDICINE. 

Or— 

li  .      Hydrargvri  chlor.  mite, 

Pulv.  sciila^ 

Pulv.  digiial., aA  gr.  '4f->2       .oi6-.032Gm.        M. 

Ft.  pil.  No.  j. 

SiG. — One  such  pill  every  three  or  four  hours. 

If  urgemic  convulsions  occur,  use  the  hot-air  bath,  cuppin<;  over 
the  kidneys,  hypodermic  injections  oi pilocarpine  nilras,  the  inhala- 
tion of  chloroformum,  or,  may  be,  the  rectal  use  of  chloral  hydrate 
with  or  \s\\\\o\x\.  potassii  brotnidum.  Urasmic  symptoms  are  often  re- 
markably controlled  by  full  doses  of  sodii  bertzoas.  The  elimination 
of  the  poison  producing  the  convulsions  is  assisted  by  the  high  bowel 
enema  of  the  normal  salt  solution. 

For  scarlatinal  rheuviatistn  the  use  oi  ferritin  alternately  with  the 
following : 

R.     Ammonii  salicyl., z^V]  8.  Gm. 

Elix.  simplicis, f.^ss  15.  Cc. 

Syr.  simplicis, f ?j  30.  Cc. 

Tinct.  card.  CO. , fSss  15.  Cc.  M. 

SiG. — Teaspoonful,  diluted,  four  times  daily. 

For  infiammation  of  the  middle  ear  it  is  much  better  to  puncture 
the  drum  membrane  than  to  allow  its  ulceration  ;  insufflations  of 
acidum  boricitm  and  the  internal  use  of  ammonii  chloridiim. 

For  the  various  other  sequclcB  the  treatment  is  the  same  as  if  they 
occurred  primarily,  ^///J  tonics. 

The  disease  being  contagious,  every  means  should  be  taken  to 
prevent  its  spread — to  wit,  isolation,  cleanliness,  disinfection,  and 
fumigation. 

Small  doses  of  quinina,  in  those  exposed,  is  said  to  prevent  or 
modify  the  severity  of  an  attack,  but  no  true  prophylactic  is  known. 


MEASLES. 

Synonyms.     Morbilli ;  rubeola. 

Definition.  An  acute  <f//V/<?wzV  and  contagious  disease;  charac- 
terized by  catarrhal  symptoms,  referable  to  the  naso  broncho-pul- 
monary mucous  membrane,  fever,  and  a  crimson  mottled,  papular, 
eruption  which  terminates  by  desquamation. 


FEVERS.  57 

Cause,  A  specific  micro-organism,  with  a  special  susceptibility 
for  childhood.  Contagious  by  contact,  and  can  be  communicated  by 
inoculation.  One  attack,  as  a  rule,  protects  from  a  second,  hicuba- 
tion,  ten  to  fourteen  days. 

Pathological  Anatomy.  There  are  no  special  anatomical 
characters  exclusive  of  the  eruption,  which  is  considered  among  the 
symptoms  of  the  disease. 

Symptoms.  Onset  gradual,  following  a  chill  or  with  irregular 
chills,  fever,  the  temperature  rising  to  ioi°  or  102°,  viuscuiar  soretiess, 
headache,  and  intense  nasal,  pharyngeal,  and  laryngeal  catarrh. 
The  eyes  are  reddened  and  suffused  and  tears  flow  over  upon  the 
face.  The  throat  is  reddened  and  swollen.  On  the  evening  of  the 
second  day  a  decided  remission  takes  place  in  the  fever,  the  catarrh 
continuing  ;  on  the  fourth  day  occurs  an  eruption  of  a  crimson  color 
on  the  face,  soon  spreading  over  the  body,  in  the  form  of  papules  and 
blotches,  which  coalesce  into  irregular  circles  or  ^r^j^f^/i',  with  islands 
of  white  skin  between,  and  with  the  appearance  of  the  eruption  the 
fever  returns,  the  catarrh  is  aggravated,  but  the  character  of  the  dis- 
charge, instead  of  remaining  clear  and  watery,  becomes  turbid,  thick, 
and  yellowish,  and  extends  to  the  bronchial  mucous  membrane. 
About  the  ninth  day  (the  fourth  of  the  eruption),  the  eruption  fades, 
the  symptoms  abate,  and  slight  desquamation  occurs.  Some  cough 
and  catarrh  may  remain  for  a  long  period. 

Black  measles,  sometimes  called  hemorrhagic  rubeola,  or  camp 
measles,  is  a  variety  occurring  in  camps  and  jails,  in  which  occur 
dangerous  chest  symptoms,  and  black  spots  or  petechiae  from  deteri- 
orated blood,  and  severe  prostration. 

Koplik,  in  1896,  described  a  peculiar  eruption  found  on  the  buccal 
mucous  membrane  (lining  lips  and  cheeks  only),  consisting  "  of  small, 
irregular  spots  of  a  bright  red  color;  in  the  center  of  each  spot  a 
most  minute  bluish-white  speck.  These  minute  bluish-white  specks 
in  the  center  of  a  reddish  spot  are  pathognomonic  of  beginning 
measles."  I  have  almost  invariably  found  them  at  the  onset 
of  the  chill  and  catarrhal  symptoms,  and  been  able  to  make  a 
diagnosis  before  the  characteristic  eruption  of  meatles  appeared. 
These  tiny  spots  fade  with  the  appearance  of  the  mottling  of  the 
skin. 

Rather  common  complications  are  tonsillitis,  and  lobar  or  catarrhal 
pneu7nonia. 
6 


58  PRACTICK   OF    MEDICINE. 

Sequelae.  In  tliose  o{  s/rumous  diathesis,  scrofula  or  tuberculosis 
may  develop. 

Diagrnosis.  A  typical  case  begins  gradually,  with  chilliness, 
nasal  catarrh,  watery  eye,  and  fever,  which  decline  before  the  erup- 
tion, rising  afterward  ;  the  eruption  is  crescentic  in  shape  and  of  a 
crimson  color,  beginning  on  face,  followed  by  desquamation.  If  ex- 
perience shall  determine  that  the  eruption  mentioned  as  occurring  on 
the  buccal  mucous  membrane  at  the  onset  is  invariable,  the  diagnosis 
will  be  readily  determined. 

Scarlet  fever :  absence  of  catarrh,  and  earlier  appearance  and  dif- 
ferent character  of  the  eruption,  with  high  fever  and  rapid  pulse. 

Prognosis.  As  a  rule,  a  jjerfect  recovery.  If  tuberculosis  de- 
velop, the  prognosis  is  bad.     Black  measles,  the  majority  succumb. 

Treatment.  No  specific.  Mild  cases  require  no  medicine,  sim- 
ply regulating  the  diet  and  bowels,  and  cool  sponging;  the  indica- 
tions are  to  render  the  patient  as  comfortable  as  possible,  the  disease 
pursuing  a  favorable  course  without  therapeutical  interference. 

If  the  febrile  reaction  is  high,  the  following  soon  controls  it : 

K  •     Tinct.  aconiti  rad., Tt\^ss-j  .03-.06  Cc. 

Spts.  Ktheris  nitrosi, TTLx-xv  .6-1.       Cc. 

Liquor  jwtassii  citrat.,    .    .    .    .adfgj  4.              Cc. 
Every  two  hours. 

For  Xht  pruritus  of  the  entption,  the  local  use  of  oi!s  and  fats,  par- 
ticularly of  eucalyptol,  foss-j  (2-4  Cc),  U7ig.  pctrolei,  5J  (30  Gm.). 
For  catarrhal  symptoms,  inunction  of  the  nose,  neck,  and  chest 
with  camphorated  oil  and  small  doses  oi pulv.  ipecac,  et  opii  at  bed- 
time; if  the  catarrh  extends  to  the  bronchial  mucous  membrane, 
expectorants. 

During  convalescence,  for  the  strumous,  protect  from  exposure, 
and  administer  oleum  viorrhuce  with  syr.  ferri  iodidi.  For  black 
measles,  bold  stimulation,  z.T\d,  ferrttm  and  quinina. 


RUBELLA. 

Synonyms.      Rotheln ;    epidemic    roseola ;    German    measles ; 
French  measles;  false  measles. 
Definition.     An  acute,  self-limited,  contagious  disease;  charac- 


FEVERS.  59 

terized  by  mild  fever,  suffused  eyes,  cough  and  sore  throat,  enlarge- 
ment of  the  lymphatic  glands  of  the  neck,  and  a  rose-colored  eruption, 
in  patches  of  irregular  size  and  shape,  appearing  on  the  first  day. 

Many  so-called  second  attacks  of  measles  and  scarlet  fever  are 
attacks  of  rubella  (Tyson). 

Cause.  Propagated  by  contagion.  That  a  peculiar  germ  exists 
is  probable,  but  thus  far  it  has  not  been  isolated.  Incubation  from 
one  to  three  weeks. 

Rubella  bears  the  same  i^elation  to  measles  that  chicken-pox  does  to 
small-pox  (Tyson). 

Symptoms.  Onset  sudden,  with  mild  fever ^  suffused  eyes,  with 
little  or  no  coryza,  sore  throat,  and  enlargement oi  \he  cervical g/ands, 
not  limited  to  those  about  the  angle  of  the  jaw,  as  in  scarlatina. 
Any  time  from  the  first  to  the  foifrtk  day  appear  rose-colored  spots, 
size  of  a  pin-head,  slightly  elevated,  which  coalescing,  form  irregular 
shaped  and  sized  patches,  with  intervening  healthy  skin,  fading  on 
the  upper  part  of  the  body  while  just  appearing  on  the  lower.  Symp- 
toms all  terminate  within  a  week  by  lysis,  the  patient  showing  no  ill 
effects  from  the  attack. 

Diagnosis.  From  scarlet  fever,  by  absence  of  high  fever,  the 
rapid  pulse,  the  color  and  character  of  the  eruption,  and  the  sequelee. 

From  measles,  by  absence  of  intense  catarrhal  symptoms,  the  late 
appearance  of  eruption,  and  its  crescentic  shape. 

Prognosis.     Most  favorable. 

Treatment.  Mild  laxatives  and  restricted  diet.  \i  fever  high, 
saline  mixture.  For  itching  of  skin,  sponging  with  vinegar  and  water, 
or  inunction  with  vaseline. 


SMALL-POX. 

Synonym.    Variola. 

Definition.  An  acute  epidemic  and  cotitagious  disease  ;  charac- 
terized by  severe  lumbar  pains,  vomiting,  and  an  initial  fever,  lasting 
from  three  to  four  days,  followed  by  an  eruption,  at  ^xst  papular,  then 
vesicular,  and  afterward  pustular ;  the  development  of  the  pustule 
being  accompanied  by  a  secondary  fever,  during  the  presence  of 
which  grave  complications  are  prone  to  occur. 

Causes.     A  specific  poison  whose  nature  is  unknown,  maintaining 


60  PRACTICE    OF    MEDICINt. 

its  contagious  vitality  for  a  long  period.  "There  is  no  contagion  so 
strong  and  sure  as  that  of  smallpox,  and  none  that  operates  at  so 
great  a  distance  "  (Watson).  There  is  no  period,  from  the  initial 
fever  to  tlie  final  desquamation,  when  the  disease  is  not  contagious, 
although  the  stage  of  suppuration  is  the  most  virulent.  One  attack, 
as  a  rule,  protects  from  a  second.  Viiicinaiion  has  a  positive  pro- 
tective influence  from  the  disease,  an  extensive  observation  having 
fully  proven  that  in  proportion  to  the  efficiency  of  vaccination  is  the 
rarity  and  mildness  of  variola.     Incubation,  fourteen  to  sixteen  days. 

Pathological  Anatomy.  A  granular  and  fatty  degeneration 
occurs  in  the  liver,  spleen,  kidneys,  and  heart.  The  pustules  are 
found  in  the  larynx,  trachea,  bronchial  tubes,  and  on  the  pleura. 

Varieties.  Discrete;  confluent;  malignant;  varioloid  or  modi- 
fied small-pox. 

Symptoms.  Discrete  fonn.  Onset  sudden,  with  a  violent  chill, 
vomiting,  and  ^govi\i\x\<g  pains  in  the  back,  shooting  down  the  limbs; 
fever,  in  short  time  rising  to  103°  or  104°  F. ;  full,  strong,  and  rapid 
pulse,  ranging  from  100  to  130;  \}nQ  face  red,  eyes  injected,  intense 
headache,  and  sleeplessness  ;  prostration  great  from  the  very  onset. " 
Delirium  and  convulsions  occur  at  times.  During  the  third  day  the 
characteristic  eruption  makes  its  appearance,  first  on  the  forehead 
and  lips,  consisting  of  coarse  red  spots.  With  the  appearance  of  the 
eruption  all  the  marked  symptoms  of  the  fever  abate,  the  patient  feel- 
ing quite  comfortable.  On  they?////  day  oS.  the  disease  the  spots  \)&- 
com^  papules  ;  on  the  sixth  day,  transformed  into  vesicles,  which  are 
soon  uinbilicated ;  on  the  eighth  day  the  vesicles  change  io  pustules  ; 
on  the  ninth  day  the  pustules  are  entirely  purulent,  and  each  sur- 
rounded with  a  broad  red  band — the  halo  or  areola,  the  face  becom- 
ing swollen  and  the  features  distorted ;  on  the  eleventh  day,  pus 
oozes  from  the  pustules,  and  drying,  forms  the  scab,  or  crust,  which, 
on  the  seventeenth  to  twenty-first  day ,  drops  off,  leaving  a  red,  glisten- 
ing depression  ox  pit,  soon  chan*ging  into  a  white  cicatrix.  With  the 
formation  of  the  pustules  {eighth  day)  severe  rigors  7\.r\d  fever  set  in, 
and  a  characteristic  odor  is  emitted,  all  the  original  symptoms  return- 
ing. This  secondary  fever,  the  fever  of  suppuration,  is  the  most  critical 
period  of  the  disease,  and  is  generally  attended  with  violent  delirium. 
In  favorable  cases  the  secondary  fever  subsides  after  three  or  four 
days,  and  convalescence  is  established. 

Confluent  small-pox  differs  from  the  discrete  in  the  greater  severity 


FEVERS.  61 

of  all  the  symptoms  and  the  marked  prostration  of  the  patient,  the 
eruption  appearing  during  the  second  day,  the  pustules  coalescing 
into  large  patches,  causing  great  distortion  of  the  features. 

MalignaJit  small  pox  is  characterized  by  the  greater  intensity  and 
the  irregularity  of  the  symptoms,  death  resulting  before  the  character- 
istic eruption  appears,  by  convulsions  or  coma.  In  these  cases  hem- 
orrhages are  frequent  and  petechiae  are  observed. 

Varioloid,  or  modified  small-pox,  is  the  form  modified  by  previous 
vaccination,  or  by  a  former  attack  of  small-pox.  Its  course  is  shorter 
and  milder  than  the  other  forms,  the  eruption  appearing  a  day  later, 
and  is  not  attended  with  secondary  fever. 

During  some  epidemics  two  other  eruptions  are  observed,  appear- 
ing on  the  second  day,  orxQ  petechial,  in  the  form  of  a  fine  macular  or 
spotted  eruption  on  the  abdomen  and  legs,  "Simon's  triangle"  ;  the 
other  an  erythematous  eruption  on  the  sides  and  inner  surface  of  the 
legs.     Both  disappear  within  forty-eight  hours. 

Complications.  During  the  course  of  the  secondary  fever  there 
is  a  great  tendency  to  grave  inflammations,  such  as  pleuritis,  pneu- 
monitis, and  dysentery.  During  convalescetice,  boils  and  abscesses  on 
the  skin  are  frequent. 

Diagnosis.  Cannot  be  confounded  with  any  other  disease  if  it 
has  typical  symptoms,  such  as  chill,  vomiting,  pains  in  back  and  legs, 
high  fever  and  pulse,  all  declining  on  third  day,  when  the  erup- 
tion appears,  first  spots,  then  papules,  then  vesicles,  finally  pus- 
tules, drying  and  forming  crusts,  and  with  the  marked  secondary 
fever. 

Prognosis.  Depends  upon  the  variety  of  the  attack,  the  age  of 
the  patient,  and  whether  vaccinated  or  not.  Discrete,  mortality  four 
per  cent. ;  confluent,  fifty  per  cent.  ;  jnaligfiant,  all  perish.  Vnd^r  five 
years  and  ovtr  forty  years  of  age,  fifty  per  cent.  die. 

Treatment.  If  the  patient  is  seen  early,  vaccination  should  be 
performed  at  once ;  it  may  modify  the  attack.  In  the  absence  of  a 
specific,  the  treatment  is  entirely  symptomatic.  Rest  in  bed,  good 
ventilation,  the  temperature  kept  at  65°  F.,  avoiding  draughts.  For 
the  itiitial  fever,  full  pulse,  and  -p'^ms,  phenace tin,  gr.  x  (0.65  Gm.), 
or  antfebrin,  gr.  v  (0.32  Gm.),  or  aceta?iilidtini,  gr.  v-x  (0.32-0.65 
Gm.),  or,  what  is  still  better,  as  more  soluble,  antipyriti,  gr.  x 
(0.65  Gm.),  repeated  p.  r.  n.,  are  of  great  service,  rendering  the 
symptoms  more  endurable.     Depressing  doses  must  be  avoided. 


62  rRACTICE    OF    MEDICINE. 

For  llie  headache,  ice  bags  to  the  head  and  a  mustard  sinapism  to 
the  nape  of  the  neck. 

For  sleeplessness  and  restlessness  or  early  deliriion,  full  doses  of 
poiassii  bromiditm,  chloral,  or  trional. 

Y ox  secondary  fever  the  best  remedy  is  quinina,  gr.  v  (0.32  Gm.) 
every  three  hours,  and  for  cerebral  excitement  of  this  period,  either 
full  doses  of  potassii  bromidum,  by  stomach,  or  the  following  by 
rectum : 

R.     Chloral, .    .    gr.  xx  1.3  Gm. 

Mucil.  acacioe fzij  8.    Cc. 

Inf.  digitalis, ad  q.  s.  f^j  ad  30.     Cc. 

p.  r.   n. 

The  secondary  fever  being  pyaemic  in  character,  the  depression 
should  be  anticipated  by  large  doses  of  tinctitra  frrri  chloridi  and 
judicious  stimulation,  brandy  ih  tablespoonful  (15  Cc.)  doses  being 
most  efficient.  « 

From  the  onset,  milk,  eggs,  animal  broth,  oysters,  and  beef-juice 
should  be  administered  every  three  hours.  Ice  is  always  grateful  and 
should  be  given  freely,  and  if  pustules  appear  in  the  mouth,  ice 
should  be  held  in  the  mouth  as  long  as  possible,  and  washes  of 
potassii  chloras  or  acidiim  carbolicwn  employed. 

The  disease  being  contagious,  isolation,  ventilation,  cleanliness, 
and  disinfection  are  imperative. 

To  prevent  pitting,  keep  patient  in  a  dark  room,\it\S.  ventilated. 
Masks  of  some  unctuous  material,  thoroughly  applied  to  exclude  the 
air,  have  a  beneficial  effect.  Success  is  claimed  by  a  number  of  ob- 
servers from  the  use  of  collodium  applied  once  or  twice  daily.  Cold 
a/rt/^T  dressings  constantly  to  face  and  hands  are  beneficial,  besides 
allaying  heat,  pain,  and  swelling.  Hot  water  can  be  used  if  more 
grateful.  The  water  dressings  should  be  made  antiseptic  with  subli- 
mate solutions,  I  :  5000  or  i  :  10,000;  Ichthyol,  five  to  twenty  per  cent, 
solution,  painted  over  the  pustules  several  times  a  day,  is  recom- 
mended to  hasten  the  drying  up,  check  extensive  suppuration,  and 
prevent  pitting.  If  water  dressing  seem  undesirable,  anoint  the  body 
with  eucalyptol,  f^j  (4  Cc),  rubbed  into  unguentuin  petrolei,  ^j 
(30  Cc),  or  acid,  carbolic,  gr.  x  (0.65  Gm.)  to  an  ounce  (30  Cc.)  of 
vaselin  or  lanolin. 


FEVERS.  63 


VACCINATION. 


Synonyms.     Vaccinia ;  cow-pox. 

Definition.  Inoculation  with  the  matter  of  vaccinia  or  cow-pox 
— bovine  virus.  The  person  prope7-ly  vaccinated  is,  as  a  rule,  pro- 
tected from  an  attack  of  small-pox,  and  especially  from  a  severe  or 
fatal  attack. 

Vaccination  should  be  performed  at  least  twice  in  every  individual, 
during  infancy  and  at  puberty  ;  and  it  is  safer  to  have  it  again  per- 
formed if  special  exposure  be  liable  or  has  occurred. 

In  practising  vaccination  the  skin  should  be  rapidly  scraped  until 
the  true  skin  is  reached  and  is  ready  to  bleed,  the  lymph  being  then 
brushed  over  the  abraded  surface ;  or,  instead,  make  three  or  four 
horizontal  and  transverse  cuts,  about  four  lines  long,  and  rub  the 
virus  over  them  ;  a  little  blood,  but  not  much  bleeding,  should  result. 

Symptoms.  If  the  vaccination  "takes,"  on  the  third  day  a 
papule  appears ;  on  the  sixth  day  a  vesicle  has  formed,  with  a  central 
depression  ;  on  the  eighth  day  2l pustule,  fully  formed  and  distended 
with  lymph,  with  a  reddish  areola,  which  becomes  very  wide.  The 
areola  begins  to  fade  on  the  tenth  day,  the  pustule  begins  to  dry,  and 
by  the  fourteenth  day  a  brown  mahogany  scab  or  crust  has  formed, 
which  is  detached  about  the  twenty-third  day.  The  cicatrix  is  circu- 
lar, depressed,  radiated,  and  foveated,  becoming,  after  a  time,  paler 
than  the  surrounding  integument. 

During  the  course  of  a  vaccination  more  or  less  constitutional  dis- 
turbance occurs,  especially  in  children. 

Eczematous  and  papular  eruptions  often  develop  in  strumous  chil- 
dren, for  which  the  virus  is  unjustly  held  responsible. 


VARICELLA. 

Synonym.    Chicken-pox. 

Definition.  A  mild,  slightly  contagious,  febrile  affection  ;  char- 
acterized by  a  moderate  fever,  and  the  appearance  of  a  vesicular 
eruption,  drying  up  and  falling  off  in  from  three  to  five  days. 

Cause.  A  peculiar  poison  ;  attacking  only  children  ;  occurring 
sporadically  and  as  an  epidemic. 

Symptoms.     Moderate  fever,  thirst,  anorexia,  and  constipation, 


64  PRACTICE    OK    MRniCINE. 

followed  by  the  eruption  of  vesicles,  which  rapidly  dry,  and  within 
the  week  drop  off,  leaving  a  slight/;'/.  Pustules  almost  never  occur. 
Symptoms  are  so  slight  that,  were  it  not  for  the  vesicles,  the  affection 
would  be  often  overlooked.  The  eruption  appears  on  the  boiiy  and 
e.viritiiitics,  very  rarely  on  the  forehead  and  in  the  mouth. 

Prognosis.     Most  favorable. 

Treatment.  Entirely  symptomatic.  If  vesicles  on  the  face, 
efforts  may  be  used  to  prevent  pitting. 

ERYSIPELAS. 

Synonyms.  Erysipelatous  dermatitis  ;  the  rose  ;  St.  Anthony's 
fire. 

Definition.  An  acute,  specific,  infectious  disease  ;  characterized 
by  more  or  less  severe  febrile  reaction,  and  a  peculiar  inflammation 
of  the  skin  generally  of  the  neck  and  face.  This  inflammation  exhibits 
a  marked  tendency  to  spread,  to  induce  serous  infiltration  and  suppu- 
ration of  the  areolar  tissue,  and  to  affect  the  lymphatic  vessels  and 
glands. 

Cause.  A  specific  virus  ;  a  micrococcus,  the  Streptococcus  erysipe- 
losus.  Feebly  contagious.  One  attack  predisposes  to  another.  The 
etiology  of  idiopathic  (medical)  and  traumatic  (surgical)  erysipelas 
are  identical.     Incubation,  from  two  to  seven  days. 

Pathological  Anatomy.  Erysipelas  is  a  simple  inflammation — 
a  dermatitis.  The  visceral  changes,  if  any  occur,  are  of  a  septic 
character.  Infarcts  occur  in  the  lungs,  spleen,  and  kidneys.  Septic 
endocarditis  and  pericarditis  and  pleuritis  are  found  post  mortem. 
Acute  nephritis  may  occur. 

Symptoms.  Onset  sudden;  a  chill,  followed  hy  fever,  which 
soon  reaches  104°  to  105°,  frequent  pulse,  100  to  130,  coated  tongue, 
nausea  and  vomiting,  severe  pains  in  the  limbs,  with  epistaxis  in 
adults  and  convulsions  in  children,  and  often  diarrhoea.  There  i-. 
usually  more  or  less  pharyngitis,  and  even  tonsillitis,  causing  painful 
deglutition. 

Delirium  is  frequent,  and  in  those  of  alcoholic  habits  it  resembles 
delirium  tremens. 

The  eruption  soon  follows  the  chill,  beginning  in  red  spots,  which 
rapidly  coalesce  and  spread  ;  a  sense  of  heat,  tension,  and  tingling  is 
caused  hy  \h&  great  cedema,  which  presents  a  /^«^^,  i/^w/appenrance, 


FEVERS.  65 

the  swelling  being  so  great  at  times  as  to  close  the  eyes  and  distort 
the  features.  In  many  cases  small  vesicles  develop,  which  may 
coalesce,  forming  blebs  of  considerable  size,  containing  a  clear  yellow 
serum.  After  five  or  six  days  the  eruption  begins  to  subside,  the 
symptoms  abate,  the  part  affected  remaining  tender,  and  there 
occurs  moderate  desquamation. 

During  the  height  of  the  attack  albumin  appears  in  the  urine,  so 
that  the  possibility  of  urcEmic  symptoms  must  be  remembered. 

When  extensive  infiltration  into  the  areolar  tissue  ozzux's,,  the  swelling 
and  tension  become  greater,  and  it  is  t&rm&di  phlegmonous  erysipelas. 

When  the  eruption  spreads  to  different  portions  of  the  body,  it  is 
termed  erysipelas  ambulans.  Da  Costa  cites  a  case  of  migratory, 
wandering,  or  ambulans  erysipelas,  beginning  on  cheek  and  spread- 
ing from  part  to  part  until  the  entire  body  was  affected,  lasting  three 
months  and  recovering. 

Complications.  Throjnbosis  of  the  cerebral  capillaries  or  sinuses, 
or,  as  it  is  sometimes  called,  "  erysipelas  of  the  brain,"  is  explained 
by  the  intimate  anatomical  connection  of  the  facial  vein  with  the 
pterygoid  plexus  and  cavernous  sinus, 

CEdematotis  laryngitis,  from  extension  to  the  larynx. 

Pneumonia,  pleurisy,  and  meningitis  are  frequent  complications. 

Diagnosis.  Not  difficult.  The  fever,  early  spreading  eruption, 
with  burning,  swelling,  tension,  and  tingling,  and  albuminous  urine, 
distinguish  it  from  the  other  eruptive  fevers  and  erythetna. 

Prognosis.  Usually  favorable.  Unfavorable  if  it  attack  drunk- 
ards ;  if  it  become  gangrenous  ;  if  thrombosis  of  sinuses  occur,  or  if 
it  extend  to  the  larynx. 

The  convalescence,  even  from  the  mildest  attack,  is  slow,  the 
patient  continuing  weak  and  anaemic  for  several  weeks. 

Treatment.  Mildest  cases  only  require  a  laxative,  nourishing 
diet,  and  locally  vaseline  or  bismuth  oleate,  to  modify  the  heat  and 
burning. 

Professor  Da  Costa  strongly  urges  the  use  oi  free  purgatioft  before 
the  use  of  the  remedies  usually  administered.  Excellent  results  fol- 
low the  use  of: 

R.     Hydrarg.  chlor.  mitis, gr.  j  .065  Gm. 

Sodii  bicarb., gr-  ij  -'S    Gm.        M. 

Ft.  chart. 

SiG. — One  every  two  hours  until  four,  followed  by  a  saline. 
5 


66  PRACTICK    UK    MEDICINE. 

According  to  Reynolds,  aconitum  will  cut  short  a  sthenic  attack. 
He  administers  i^lss-j  (0.03-0.06  Cc.)  every  fifteen  minutes  for  the 
first  two  hours;  then  in  hourly  doses,  until  the  surface  is  moist  and 
the  temperature  lowered.  The  aconite  can  be  used  with  the  above 
powder.  The  author  corroborates  this  plan  from  a  personal  experi- 
ence.    Watch  the  kidneys. 

In  severe  cases,  after  bowel  action,  tinctura  ferti  chlor.,  n\^x-xx 
(0.6-1.3  Cc.)  every  third  hour,  well  diluted.  P\\%o  quinitia:  sulphas, 
gr.  ij  (0.13  Gm.)  every  third  hour,  Ext.  belladonna,  gr.  )i  (0.016 
Gm.),  added,  with  benefit.  The  diet  from  the  onset  should  be  of  the 
most  nourishing  character,  and  administered  at  regular  intervals. 

Professor  Da  Costa  reports  excellent  results  in  cases  with  rapid 
spreading  tendency,  from  the  use  of  pilocarpina:  Jiydrocliloras,  gr. 
Yd  (o.oil  Gm.),  hypodermically,  or  ext.  pilocarpi fliiidiim,  n\,xx-xxx 
(1.3-2  Cc),  every  two  hours.  Good  results  are  obtained  in  a  fair 
number  of  cases  from  potassiiiodidum.  1  have  obtained  good  results 
in  rapidly  spreading  cases  from  injection  of  10  Cc.  of  the  aiiti-strep- 
tococcus  serum. 

Cerebral  symptoms,  stiviiilanis,  opium,  and  chloral,  with  ice  cap. 

Extension  to  throat,  argcnti  nitras,  brushed  over  parts.  If  symp- 
toms of  oedema  of  the  glottis  develop,  tracheotomy  is  indicated. 

Locally,  soothing  applications  are  indicated — to  wit :  Vaseline,  ung. 
zinci  oxidi,  ol.  olivce  cutn  glycerin,  bismuth  cleat.,  or  ungt.  hydrar- 
gyrum. Excellent  results  are  obtained  by  the  use  of  ichthyol,  gr. 
xx-xxx  (1.3-2  Gm.),  lanolifi,  5J  (30  Gm.),  applied  on  gauze;  if  the 
face  be  the  seat  of  disease,  cover  with  a  mask  of  gauze  spread  with 
the  ointment. 

The  following  solution  painted  over  the  inflamed  area  and  beyond, 
every  two  or  three  hours,  sometimes  seems  beneficial : 

IJ.     Acid,  carholic. ,       f .^  ss  15.  Cc. 

Olei  terebinthinae,      f  5j  30.  Cc. 

Tinct.  iodi f  jjj  30.  Cc. 

Alcoholis, f_^j  30.  Cc. 

Glycerin!, f^ss  15.  Cc.  M. 

Ft.  solutio. 

Keeping  the  inflamed  parts  bathed  with  a  twenty  per  centum  solu- 
tion o{  glyceritum  boroglycerini,  occasionally  wetting  the  cloths  with 
solution  of  hydrogen  peroxid,  is  cooling,  or  gauze  spread  with  euca- 
/y//tf/ ointment,  foj  (4  Cc.)  to  an  ounce  of  lanolin,  is  soothing. 


FEVERS.  •  67 

In  the  phlegmonous  variety,  argenti  nitras,  gr.  xx  (1.3  Gm.),  spts. 
cetheris  nitrosi,  f  5  ij  (8  Cc),  brushed  over  and  beyond  the  affected 
part,  with  the  internal  use  of  large  doses  of  quinina,ferruni,  and 
stimulatits. 


DENGUE. 

Synonyms.    Break-bone  fever  ;  neuralgic  fever ;  dandy  fever. 

The  word  dengue  is  pronounced  dangay. 

Definition.  An  acute,  epidemic,  febrile  disease,  consisting  of  two 
paroxysms  of  fever  with  an  intermission.  The  first  paroxysm  is  char- 
acterized by  high  fever,  distressing  pains  in  the  joints  and  muscles, 
and  a  peculiar  eruption  ;  the  second  paroxysm  is  characterized  by 
a  milder  fever,  an  eruption  of  different  character,  attended  with 
intense  itching,  by  some  recurrence  of  the  joint  pains,  and  by 
debility. 

Cause.  Unknown  ;  but  it  is  evident  that  a  peculiar  condition  of 
the  atmosphere  has  some  influence  in  its  development,  hicubation, 
from  two  to  six  days. 

Symptoms.  Onset  sudden— ^■z/^r,  103°  to  105°,  intense  headache, 
burning  pains  in  the  temples,  backache,  severe  aching  and  swelling 
of  the  joints  and  stiffness  of  muscles,  nausea,  vomiting,  constipation, 
and  the  appearance  of  a  rash,  resembling  scarlatina,  from  which  the 
disease  has  been  mistaken  for  scarlatinal  rheumatism.  After  some 
hours  to  two  or  three  days  a  distinct  intermission  of  one  or  two  days' 
duration  obtains. 

The  onset  of  the  second  paroxysm  is  also  sudden,  but  the  symp- 
toms are  much  less  severe,  although  the  patient  is  greatly  debilitated ; 
it  is  at  this  time  that  the  characteristic  eruption  appears,  being  either 
erythetnatous  or  rubeolous,  and  attended  with  inte7ise  itching,  remain- 
ing for  about  two  days,  when  desquamation  occurs  and  convalescence 
is  established,  but  is  prolonged  by  the  great  debility  of  the  patient. 
Average  duration  of  the  disease  eight  days.     Relapses  are  common. 

Diagnosis.  Most  apt  to  be  mistaken  for  acute  articular  rheuma- 
tism, especially  during  the  frst paroxysm,  but  the  course  of  the  dis- 
ease and  the  epidemic  influence  should  prevent  such  an  error. 

The  eruption  might  mislead  for  scarlet  fever  or  measles,  were  it  not 
for  the  severe  joint  and  muscular  pains. 

On  the  first  appearance  of  the  pandemic  of  La  Grippe  in  1S89  the 


68  PRACTICE    OF    MliDlCINi:. 

simil.iiiiy  of  the  early  myalgic  symptoms  with  those  of  dengue  was 
particularly  noticeable. 

Prof^nosis.     Favorable. 

Trf»atment.     No  specific.     Entirely  symptomatic. 

At  tlie  onset,  {xo.^  purgation  and  diaphoresis. 

For  \\\^  fe7)er,  quinines  sulphas,  gr.  v  (0.32  Gm.)  every  five  hours, 
or  aniipyrin,  gr.  x-xx  (0.65-1.3  Gm.),  repeated  p.  r.  n. 

For  \\\^  pains,  opium  o\ phenacetin. 

For  the  itching,  a  lotion  of  acidum  carbolicum. 


DISEASES  OF  THE  MOUTH. 


CATARRHAL  STOMATITIS. 

Synonyms.  Simple  stomatitis ;  erythematous  stomatitis  ;  catarrh 
of  the  mouth. 

Definition.  An  acute  catarrhal  inflammation  of  the  whole  or  a 
portion  of  the  mucous  membrane  of  the  mouth  and  tongue,  charac- 
terized by  pain,  redness,  swelling,  and  disordered  secretion.  Most 
common  in  infants  and  children.  Chronic  stomatitis  occurs  mostly  in 
adults,  the  result  of  alcoholic  or  tobacco  excesses. 

Causes.  Introduction  of  hot  and  irritating  substances  into  the 
mouth  ;  difficult  dentition  ;  secondary  to  disorders  of  the  stomach,  to 
measles,  scarlet  fever,  diphtheria,  and  variola. 

Pathological  Anatomy.  The  buccal  mucous  membrane  and 
tongue  have  a  dark  red  appearance,  are  much  swollen,  the  tongue 
often  appearing  as  if  too  broad  to  lie  between  the  teeth,  the  sides 
showing  the  impressions  of  the  teeth  ;  the  secretions  are  at  first  less- 
ened, afterward  increased,  a  turbid  mucus  covering  the  cheeks,  gums, 
and  tongue. 

Symptoms.  Oral  catarrh  begins  with  the  ordinary  signs  of 
inflammation,  burning,  smarting paijt,  and  tension  in  the  mouth,  in 
those  old  enough  to   describe  their  suffering.     Very  young  children 


DISEASES   OF  THE   MOUTH.  69 

refuse  to  nurse  or  allow  their  mouth  to  be  touched,  taking  hold  of  the 
nipple,  giving  one  or  two  pulls  and  suddenly  letting  go  and  beginning 
to  cry,  have  slight  fever,  disordered  stomach,  are  freifd  and  sleep- 
less, craving  cooling  drinks. 

The  sense  of  taste  is  blunted,  and  there  is  usually  an  unpleasant, 
bitter  taste  in  the  mouth. 

If  the  catarrh  becomes  chronic,  the  breath  has  a  fetid  odor  and  the 
tongue  is  coated  in  the  morning,  the  taste  is  disordered,  and  there  is 
generally  more  or  less  depression  of  spirits. 

Diagfnosis.  If  the  buccal  cavity  be  examined,  the  condition  is 
readily  discerned. 

Prognosis.     Recovery  is  the  rule  for  the  acute  variety. 

The  chronic  cases  are  usually  due  to  the  use  of  tobacco  or  alcohol, 
and  are  only  modified  by  the  absolute  withdrawal  of  the  exciting  cause. 

Treatment.  The  most  important  point  in  the  treatment  is  the 
removal  of  the  exciting  cause,  attention  to  the  secretions  and  diet, 
and  gently  mopping  out  the  mouth  at  frequent  intervals  with  a  soft 
wad  of  absorbent  cotton  and  cold  or  iced  water,  infusum  coptis,  or 
diluted  Dobell's  solution  (see  Scarlet  Fever),  or  the  following: 

R .     Sodii  boratis, gr.  xc  6.     Gm. 

Aquas  destillat., f.^iss  45-     Cc. 

Mel.  rosse, f^iss  45.    Cc. 

In  severe  or  aggravated  cases  a  dilute  solution,  argentutn  nitras, 
gr.  ij-v  (0.13-0.32  Gm.),  aquae,  fgj  (30  Cc),  should  be  applied. 


APHTHOUS   STOMATITIS. 

Synonyms.  Follicular  stomatitis  ;  vesicular  stomatitis  ;  croupous 
stomatitis. 

Definition.  An  acute  inflammation  of  the  follicles  and  mucous 
membrane  of  the  mouth  and  tongue,  characterized  by  a  fibrinous  or 
croupous  exttdation ;  the  exudation  first  appearing  in  isolated  spots 
{aphthcB  discrete),  afterward  coalescing,  and  forming  large  and  irreg- 
ular sized  patches  {aphihce  co7tfluens),  which  rupture,  leaving  an 
ulcer,  which  slowly  heals. 

Causes.  A  disease  principally  of  childhood.  Difficult  dentition  ; 
disorders  of  digestion  ;  uncleanliness,  such  as  neglect  to  rinse  the 


70  PRACTICE    OF    MKDICINE. 

child's  mouth  after  nursing;  a  symptom  of  measles  and  diseases  of 
the  buccal  cavity. 

Pathological  Anatomy.  Begins  as  a  small,  whitish  papulo- 
vesicular elevation,  semi-transparent,  hard,  and  tender,  with  a  distinct 
red  zone  about  the  base ;  there  may  be  as  few  as  six  or  as  many  as 
twenty;  they  may  remain  isolated  {aphtha  discrete)  or  coalesce 
{aphthcs  conjluens) ;  they  are  regarded  as  either  a  peculiar  deposit  or 
a  local  croupous  exudation.  After  a  day  or  two  they  rupture,  leaving 
an  irregular  white  or  grayish  ulcer,  which  slowly  heals.  The  seat  of 
the  affection  is  the  internal  surface  of  the  lips  and  cheeks,  the  gums, 
tongue,  and  roof  of  the  mouth. 

Symptoms,  The  condition  begins  with  redness  of  the  mucous 
membrane  of  the  mouth,  followed  rapidly  by  the  spots  or  vesicles  on 
the  inner  surfaces  of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks  ; 
in  infants  the  pain  is  so  severe  that  the  child  refuses  to  nurse ;  in 
older  children, /(?/«  from  talking,  Diastication,  and  deglutition ;  saliva- 
tion is  marked,  the  saliva  dribbling  from  the  moufli.  There  is  slight 
feverishness,  fretfulness,  and  sleeplessness.  Digestion  is  impaired, 
and  quite  commonly  diarrhoea  occurs.  A  disagreeable,  penetrating 
odor  escapes  from  the  buccal  cavity. 

Diagnosis.  Impossible  to  confound  with  any  other  affection  if 
the  buccal  cavity  is  examined. 

Prognosis.     Always  favorable. 

Treatment.  Removal  of  the  exciting  cause.  Attention  to  the 
dietary  and  the  secretions  is  paramount.  If  constipation  occur, 
the  use  of  a  few  powders  of  hydrargyri  chloridum  mite,  containing 
gr.  y^j  (0.005  Gm.),  adding  a  small  amount  of  sodii  bicarbonas  or  small 
doses  oi pepsinutn.  Also  small  doses  oi  infuswn  coptis,  which  seems 
to  have  also  a  specific  action  in  all  forms  of  stomatitis  and  gastritis. 
Protracted  cases  require  tonic  doses  of  quinina  sulphas. 

Locally,  good  results  are  obtained  from  strong  solutions  o^  potassii 
chloras,  infusum  coptis,  or  touching  the  ulcers  with  argentinitras. 


ULCERATIVE  STOMATITIS. 

Synonyms.     Diphtheritic  stomatitis;  gingivitis  ulcerosa. 
Definition.     An  acute  diphtheritic  inflammation  of  the  mucous 
membrane  of  the  mouth,  continuing  until  extensive  and  unhealthy 


DISEASES   OF  THE   MOUTH.  71 

ulcerations  occur.  It  usually  begins  on  the  margin  of  the  lower  gums, 
and  often  extends  to  the  lips,  cheeks,  or  tongue. 

Causes.  Usually  seen  in  children  only.  Most  frequently  in  the 
families  of  the  poor,  the  result  of  unfavorable  hygienic  surroundings, 
personal  uncleanliness,  and  poor  food.  Often  seen  in  those  reduced 
by  severe  acute  disease.  Perhaps  contagious,  as  epidemics  are  not 
rare.  Prevails  in  institutions,  jails,  and  camps,  in  which  the  sanitary 
conditions  are  defective. 

Pathological  Anatomy.  The  gums  first  appear  congested, 
swollen,  bleeding  readily,  and  separated  from  the  teeth  ;  soon  a  firmly 
adherent  deposit  in  the  form  of  patches  appears,  at  first  whitish, 
speedily  becoming  gray  or  even  black,  from  disintegration,  becoming 
soft  and  pulpy,  the  separated  slough  leaving  irregular-shaped  ulcers, 
with  raised  margins,  from  oedema  of  the  surrounding  tissue.  They 
are  not  deep,  and  their  surface  is  covered  with  a  pulpy,  yellowish 
substance.  The  morbid  process  usually  extends  to  the  inner  side  of 
the  lips,  cheeks,  and  to  the  tongue. 

Symptoms.  Begins  with  swelling  of  the  mucous  membrane 
about  the  base  of  the  teeth,  followed  with  pain  aggravated  by 
jnastication  or  deglutition  ;  food  and  drink  must  be  of  the  bland- 
est character.  The  mouth  is  hot,  the  sali^ia  dribbles  away,  mixed 
with  blood  and  shreds  of  pulpy  jnatter,  the  breath  is  fetid,  the  appe- 
tite, digestion,  and  bowels  disordered.  The  patient  is  feverish,  fretful, 
and  sleepless. 

There  is  always  enlargement  and  tenderness  of  the  submaxillary 
glands. 

The  affection  is  often  associated  with  entcro-colitis. 

Diagnosis.  Apt  to  be  confounded  with  gangrenous  stomatitis, 
than  which,  however,  there  are  less  constitutional  symptoms  and  a 
slower  course  of  the  malady. 

Prognosis.  Favorable.  If  promptly  and  properly  treated,  the 
ulcerated  surface  heals  rapidly,  although  quite  commonly  some  teeth 
are  lost. 

Treatment.  The  etiology  of  the  affection  must  be  borne  in  mind 
and  remedied.  Strict  attention  to  the  diet,  to  the  secretions,  and  ab- 
solute cleanliness. 

Internally,  the  prompt  use  oi  potassii  chloras,  gr.  j-v  (0.065-0.32 
Gm.),  alone  or  with  itifusum  coptis,  frequently  repeated,  often  acts  like 
a  specific.  The  general  health  frequently  calls  for  quinina,ferrum,  and 
stimulants. 


72  PRACTICE   OF    MEDICINE. 

Locally,  a  strong  solution  of  potassti  chloras,  or  keeping  the  ulcer 
covered  with  bisviuth,  or  frequent  applications  of  alumen  exsiccatutn 
are  valuable.  Cases  which  resist  these  remedies  should  have  applied 
the  following  combination,  proposed  by  the  late  Dr.  Dewees  : 

R.     Cupri  sulphat. gr.  x  .65  Gm. 

I'ulv.  cinchonie  opt., gr.  cxx  8.       Gm. 

Pulv.  g.  arab. , gr-  Ix  4.       Gm. 

Mel.  commun., f  3  0  ^'       ^'-* 

Aquoefont., fo'ij  90-       Cc. 

Ft.  sol. 

SiG. — The  ulceration  to  be  touched  twice  daily  with  the  point  of  a  camel's 
hair  pencil. 

If  a  spreading  tendency  develop,  the  application  of  argenti  nitras 
dilutus,  or  a  diluted  solution  of  acidum  nitricum,  is  indicated. 


THRUSH. 

Synonyms.     Parasitic  stomatitis;  muguet;  sprue;  white  mouth. 

Definition.  An  inflammation  of  the  mucous  membrane  of  the 
mouth,  associated  with  or  caused  by  the  growth  of  2i  parasitic  plant, 
the  oidium  albicans  ;  characterized  by  pain,  disorders  of  digestion  and 
of  the  bowels. 

Causes.  The  development  of  the  thrush-fungus  oidium  albicans, 
is  promoted  by  all  those  conditions  designated  as  unhygienic,  by  de- 
bilitated conditions  of  the  general  system,  and  by  neglect  to  thor- 
oughly rinse  the  mouth  after  nursing  or  bottle-feeding.  It  is  claimed 
that  a  catarrhal  stomatitis  is  the  soil  upon  which  the  fungus  develops. 

The  age  is  considered  a  predisposing  cause,  seldom  being  seen 
after  two  years  of  age.  In  adults,  only  toward  the  last  stages  of 
cancer  or  consumption. 

Pathological  Anatomy.  The  mucous  membrane  of  the  mouth 
presents  a  dark  red  appearance  in  isolated  patches,  on  which  whitish 
points  appear,  which  rapidly  coalesce  into  l.irge  areas.  They  closely 
resemble  curdled  milk,  from  their  soft  consistency.  These  whitish 
points  consist  of  epithelium  and  fat,  in  which  are  embedded  the 
sporules  and  filaments  of  the  fungus. 

The  deposit  first  appears  about  the  angles  of  the  mouth,  soon 


DISEASES   OF  THE   MOUTH.  73 

extending  to  all  parts  of  the  cavity,  often  to  the  pharynx  and 
oesophagus.  The  mouth  is  usually  swollen  and  tender,  the  breath 
often  fetid. 

Symptoms.  Pain,  aggravated  by  nursing  or  mastication.  The 
lips  are  swollen,  the  saliva  is  increased,  the  breath  hot  and  some- 
what fetid.  There  is  usually  increased  temperature.  Diarrhcsa  is 
frequent,  the  stools  green  and  sour,  causing  an  erythema  of  the 
buttocks. 

Diagnosis.  The  curd-like  appearance  of  the  deposit,  showing 
the  presence  of  the  fungus  upon  microscopical  examination,  will 
prevent  error.  Should  not  be  confounded  with  aphthous  stomatitis, 
in  which  ulcers,  preceded  by  the  formation  of  vesicles,  are  perfectly 
distinctive. 

Prognosis.  Favorable,  unless  occurs  toward  the  termination  of 
exhausting  diseases. 

Treatment.     Absolute  cleanliness  of  the  mouth  is  all-important. 

Internally,  remedies  should  be  directed  to  the  removal  of  the  dis- 
orders of  the  gastro-intestinal  tract. 

Prompt  relief  has  followed  the  use  of  sodii  hyposulphitis  saturat. 
solut.,\^\\]-yi  {o.iZ-o.6  Cc),  every  two  or  three  hours,  and  the  local 
application  of  the  same  solution. 

Locally,  solutions  of  sodii  boras  often  answer  every  indication,  the 
best  vehicle  htmg  glyceri7iu7n  or  infusum  coptis,  and  not  mel  ox  sac- 
charum,  a  good  formula  being  : 

R .     Sodii  boratis, gr.  Ix  4.       Gm. 

Glycerini, fjij  8.       Cc. 

Aquse, ^3'^]  24.       Cc. 

SiG. — Thoroughly  applied  four  or  five  times  daily,  and  continued  for  a  week 
after  the  disappearance  of  the  affection. 


GLOSSITIS. 

Definition.  An  inflammation  of  the  parenctiyma  of  the  tongue ; 
characterized  by  great  swelling  of  the  organ,  with  difficult  mastica- 
tion, deglutition,  and  vocalization. 

The  affection  may  be  either  acute  or  chronic. 

Causes.  The  acute  variety  is  usually  the  result  of  some  direct 
irritation  to  the  tongue,  such  as  direct  injury,  contact  of  boiling 
7 


(4  PRACTICE    OF    MEDICINE. 

liquids,  the  action  of  acrid  or  corrosive  substances,  or  the  sting  of  the 
tongue  by  an  insect,  such  as  the  bee  or  wasp. 

The  cJironic  variety  is  generally  circumscribed  ;  it  may  follow  the 
acute;  be  due  to  the  sharp  edges  of  the  teeth,  or  the  use  of  a  tobacco 
pipe. 

Pathological  Anatomy.  Acute  glossitis  begins  with  intense 
hyperemia,  redness,  and  swelling  of  the  organ  ;  the  size  often  be- 
comes so  great  that  the  tongue  is  too  large  for  the  mouth,  and  thus 
protrudes  between  the  teeth  ;  its  surface  is  covered  with  a  thick 
secretion,  and  it  becomes  of  a  pale  or  grayish  color.  The  swelling 
may  rapidly  decline,  or  abscesses  may  form,  which  leave  a  more  or 
less  decided  depressed  cicatrix. 

Chronic  glossitis  occurs  usually  along  the  edges  of  the  organ,  the 
cicatricial  changes  being  in  circumscribed  hard  spots.  If  the  entire 
tongue  is  affected  with  chronic  inflammation,  the  action  is  superficial, 
and  has  been  termed  "  psoriasis  of  the  mouth." 

Symptoms.  Acute  glossitis  begins  rather  abruptly  with  fever, 
increased  pulse,  restlessness,  anxiety,  enlargement  of  the  tongue,  a 
sensation  of  Iteat  in  the  mouth,  with  pain,  and  increased  flow  of 
saliva.  Alastication  and  deglutition  become  difficult  if  not  impossible, 
the  voice  jnujffled,  and  dyspfiosa  decided.  Theglands  at  the  angles  of 
the  jaws  are  enlarged,  which,  in  turn,  compress  the  vessels  of  the  neck. 

When  suppuration  supervenes,  the  constitutional  symptoms  become 
severe  and  the  oral  symptoms  are  intensified.  Death  has  occurred 
from  suffocation  in  severe  cases. 

Chronic  glossitis  presents  pain  as  the  chief  symptom,  aggravated 
by  movements  of  the  organ. 

Diagnosis.  The  rapid  course  of  acute  glossitis  should  prevent  its 
being  mistaken  for  any  other  affection. 

Chronic  glossitis,  if  severe,  might  be  mistaken  for  cancer  of  the 
tongue,  although  the  slow  and  mild  progress  of  the  former  contrasts 
strongly  with  the  rapid,  severe,  and  painful  course  of  the  latter,  with 
its  marked  constitutional  symptoms. 

Prognosis.  Acute  glossitis  usually  terminates  in  recovery  within 
a  week,  although  the  danger  of  suffocation  must  always  be  remem- 
bered. 

Chronic  glossitis  is  an  incurable  malady  in  the  majority  of  in- 
stances. 

Treatment.     For  acute  glossitis  prompt  measures  are  demanded. 


DISEASES   OF  THE   MOUTH.  75 

For  the  fever  and  rapid  pulse,  tinctura  aconiti,  y\,  j-iij  (0.06- 
0.18  Cc.)  every  half  hour  or  hour  until  its  physiological  effects  are 
produced. 

For  the  enlargement  of  the  organ,  either  ice  constantly  applied 
internally  and  externally,  at  the  angles  of  the  jaw,  or  the  persistent 
use  of  hot  water  held  in  the  mouth  and  externally  ;  if  prompt  relief 
does  not  follow  these  measures,  or  if  the  case  is  an  aggravated  one, 
the  prompt  deep  scarification  of  the  tongue  must  be  resorted  to. 

If  abscesses  form,  promptly  open  them  and  administer  quinincB 
sulphas. 

If  suffocation  appear  imminent,  tracheotomy  must  be  performed. 

Yox  chronic  glossitis,  the  removal  of  the  exciting  cause  and  the  local 
use  of  argenti  nitras  to  the  ulcerated  edges. 

"  For  psoriasis  of  the  tongue,"  the  local  use  oi  argetituni  or  acidum 
carbolicu7n. 

The  general  health  must  always  receive  proper  attention. 


GANGRENOUS  STOMATITIS. 

Synonyms.     Cancrum  oris  ;  noma ;  water-cancer. 

Definition.  An  acute,  rapidly  progressive  gangrenous  ulceration 
of  the  mouth,  leading  to  extensive  sloughing  and  destruction  of  the 
affected  tissues. 

Causes.  It  is  probable  that  gangrenous  stomatitis  is  due  to  some 
parasitic  micro-organism,  but  its  character  is  as  yet  unknown.  It 
attacks  feeble  and  sickly  children  by  preference ;  now  and  then 
observed  in  adults. 

It  is  seen  as  a  primary  affection  ancf  as  a  sequelae  to  measles, 
scarlet  fever,  typhoid  and  typhus  fevers,  and  pneumonia. 

Pathological  Anatomy.  The  process  is  essentially  a  rapidly 
progressive  moist  gangrene. 

Symptoms.  Noma  usually  begins  insidiously  by  the  destructive 
process  developing  upon  an  ulcerative  stomatitis,  or  the  appearance 
of  a  sloughing  ulcer  on  the  gums  or  the  inside  of  the  cheek  of  an 
apparently  healthy  mucous  membrane.  Often  the  gangrenous  odor 
is  the  first  symptom  noted.  The  cheek  swells,  becomes  csdetnatous, 
and  the  skin  waxy  looking  ;  within  a  day  or  two  the  process  may 
spread,  involving  the  whole  side  of  the  face,  and  as  the  ulcer  becomes 


76  PRACTICE    OF    MEDICINE. 

deeper  and  approaches  in  its  progress  the  integument,  the  skin  be- 
comes red,  blue,  purple,  black,  or  a  combination  of  these  shades, 
followed  by  the  develoi)ment  of  a  bulla  filled  with  ichorous  fluid,  the 
skin  softening  and  breaking  down. 

The  constitutional  reaction  is  very  severe  ;  puhe  rapid  and  feeble  ; 
temperature  I02°-I04°  F. ;  extreme  prostration  ;  pain  but  little  com- 
plained of,  but  the  odor  fills  the  house  ;  diarrhoea  is  common,  hemor- 
rhages from  the  mouth  rare.  Death  usually  occurs  in  a  week  to  ten 
days,  the  patient  often  presenting  a  frightful  picture.  Very  rarely 
recovery  occurs. 

Diagnosis.  No  other  disease  or  condition  can  be  confounded 
with  gangrenous  stomatitis. 

Prognosis.     Nearly  all  cases  die. 

Treatment.  There  is  but  little  to  say  about  the  treatment  of  noma. 
Destruction  of  the  ulcer  by  the  use  of  argentutn  nitras  in  stick,  fum- 
ing acidum  niiricum,  or  the  Paquclin  cautery  might  be  tried.  Washes 
of  antiseptic  solutions,  and  the  application  of  quantities  of  finely 
powdered  acidum  boricum  are  useful.  Keep  up  the  strength  of  the 
patient  with  ferruvi,  arsenicum,  quinince  sulphas,  and  stimulants. 


DISEASES  OF  THE  STOMACH. 


ACUTE  GASTRIC  CATARRH. 

Synonyms.  Acute  simple  gastritis  ;  gastric  fever  ;  bilious  fever; 
acute  indigestion  ;  subacute  gastritis. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  ;  characterized  by  feverishness,  loss  of 
appetite,  nausea,  with  occasional  vomiting,  painful  digestion,  irregu- 
larity of  the  bowels,  and  in  severe  attacks,  vertigo  {stomachic  vertigo). 

Causes.  Deficient  quantity  of  or  quality  in  the  gastric  juice. 
Errors  in  diet,  insufficient  mastication   of  food,  swallowing  liquids 


DISEASES   OF  THE   STOMACH.  77 

which  are  either  too  hot  or  too  cold,  and  particularly  the  abuse  of 
alcoholic  liquors,  cold  beer,  and  iced  soda-water.  Certain  drugs  in 
medicinal  doses,  such  as  iodides,  bromides,  and  arsenic. 

Often  secondary  to  infectious  diseases,  such  as  scarlet  fever,  measles, 
smallpox,  diphtheria,  and  typhoid  fever.  Occasionally  the  result  of 
wet,  changeable  weather. 

Patholog'ical  Anatomy.  The  mucous  membrane  is  irregularly 
congested  and  engorged,  and  covered  with  a  grayish,  semi-transparent 
and  tenacious  mucus,  having  an  alkalme  reaction.  The  true  gastric 
juice  is  secreted  in  lessened  amount  or  is  entirely  suspended. 

Symptoms.  At  first,  loss  of  appetite,  at  times  disgust  for  food, 
heavily  coated  tongue,  bad  taste  and  breath,  persistent  nausea,  and 
at  times  z/ojnififtg,  first  of  undigested  food,  then  viscid  mucus,  acid  and 
bitter,  and,  finally,  bilious  matter  ;  moderate  irritative  fever  xs  present, 
with  headache,  considerable  thirst,  and  flashes  of  heat  with  sensations 
of  burning  in  the  palms  of  the  hands  and  soles  of  the  feet ;  acid  drinks 
eagerly  sought  after ;  digestion  imperfect,  giving  rise  iopain,  tenderness, 
feeling  of  weight,  and  eructations ;  bowels  may  be  loose,  but  are 
oftener  constipated.  Vertigo  with  pain  in  the  nucha  is  a  prominent 
symptom  in  many  cases,  causing  great  anxiety  and  depression  of 
spirits.     The  urine  is  scanty,  containing  lithates  and  pigment. 

The  symptoms  are  aggravated  by  errors  in  diet,  and  if  saccharine 
or  fatty  articles  are  taken  heartburn  occurs. 

Tov/ard  the  termination  of  an  attack,  herpetic  eruptions  appear 
about  the  mouth. 

Diagnosis.  Acute  gastric  catarrh  with  fever  may  be  confounded 
with  remittent  and  typhoid  fever  of  the  first  week,  but  all  doubts  will 
disappear  as  these  maladies  develop. 

The  vertigo  may  be  mistaken  for  cerebral  disease,  but  the  disap- 
pearance of  this  symptom  when  stomachic  treatment  is  inaugurated 
removes  all  apprehension. 

Prognosis.  Favorable.  Duration  about  a  week  ;  recovery  slow, 
even  under  treatment,  as  far  as  perfect  digestion  is  concerned. 

Treatment.  Give  the  stomach  as  complete  a  rest^s  possible,  and 
as  anorexia  is  a  prominent  symptom,  the  error  should  not  be  made 
of  insisting  upon  the  patient  eating  for  a  day  or  two  at  least. 

If  the  stomach  is  overloaded,  a  rare  incident,  an  ipecac  emetic,  or 
apomorphincE  hydrochloras,  gr.  y%  (0.008  Gm.),  by  hypodermic  injec- 
tion, is  indicated,  or,  if  vomiting  has  begun,  it  may  be  encouraged  by 


78  PRACTICK    OF    MEIJICINK. 

swallowing  large  draughts  of  hot  "water,  which  will  act  as  a  sedative 
if  the  stomach  be  empty. 

The  majority  do  better  by  an  active  purgation  with  either  hydrar- 
gyri  chloridi  mite,  gr.  v-x  (0.32-0.65  Gni.),  with  sodii  bicarbonas, 
gr.  V  (0.32  Gm.),  followed  in  six  or  eight  hours  with  an  ounce  dose 
magnesii  sulphas,  or  a  full  dose  of  Hunyadi  Janos  water;  or  small 
doses  every  two  hours  of  powders  containing — 

R.     Hydrarg.  clilor.  mite, gr.  ^-^  .016-.032  Gm. 

Sodii  bicarb., gr-  ij  -13             Gm.   M. 

Every  two  hours  for  a  dozen,  followed  the  second  morning  after  the  last 
powder  with  a  saline  purgative. 

After  the  stomach  and  bowels  have  been  thoroughly  cleansed,  the 
diet  may  be  more  liberal,  and  some  one  of  the  following  drugs  used  : 
tinctura  nucis  vomica,  n\,v-xv  (0.3-1  Cc),  well  diluted,  every  four 
hours,  or  pepsinum  or  papoid.  The  following  is  an  excellent 
stomachic  sedative : 

IJ.     Sodii  bicarb., ^iij  12.  Gm. 

Bismuth,  subnit., 2'j  8-  Gm. 

Aq.  chloroformi f  5  i'j  90'  Co. 

M.  et  adde 

Aq.  menthrc  pip., f^j  30.  Cc. 

Aq.  lauro-cerasi, f^ij  60.  Cc.  M. 

SiG. — Tablespoonfal  four  times  a  day. 

Another  excellent  formula  after  the  acute  symptoms  have  subsided 
is: 

R.     Strychninae  sulphas gr.  ss  .03  Gm. 

Acid,  hydrochlorici  dil.,    .    .    .    .  f .^  iv  15.       Cc. 

Glycerini, f  5j  30.       Co. 

Tinct.  card.  comp. , f,5ss  15.       Cc. 

Aq.  lauro-cerasi, f^j  30.       Cc.  M. 

SiG. — One  teaspoonful,  diluted,  four  times  daily. 


ACUTE  TOXIC  GASTRITIS. 

Synonym.    Toxic  gastritis. 

Definition.  An  acute  and  violent  inflammation  of  the  mucous, 
submucous,  and  muscular  coats  of  the  stomach,  with  loss  of  tissue; 
characterized  by  great  pain,  constant  vomiting  of  blood-streaked 


DISEASES   OF   THE   STOMACH.  79 

or  bloody  mucus,  and  whatever  may  be  ingested,  and  symptoms 
of  collapse. 

Causes.  Ingestion  of  irritant  and  corrosive  poisons,  such  as  the 
mineral  acids,  arsenic,  corrosive  sublimate,  copper,  and  carbolic  acid. 

Patliolog"ical  Anatomy.  The  mucous  membrane  is  vividly 
red  and  injected,  more  marked  at  some  portions  than  at  others  ;  it  is 
soft  and  friable  ;  erosions  are  irregularly  scattered,  and  the  submu- 
cous, muscular,  and  at  times  serous  coats  show  decided  destructive 
changes.  The  gastric  tubules  are  destroyed  in  large  numbers.  In 
many  cases  the  oral  mucous  membrane  presents  signs  of  severe  in- 
flammation. 

Symptoms.  Immediately  or  soon  after  swallowing  the  irritant 
there  ensues  a  deadly  natisea,  with  rapid  and  persistent  vomiting ; 
first,  of  the  contents  of  the  stomach  acted  upon  by  the  poison,  after- 
ward, shreds  of  mucous  membrane  and  blood  clots ;  there  are  also 
present  great  anxiety  and  depression,  a  weak,  rapid  pulse,  slow  and 
shallow  respiration,  cold  skin,  covered  with  a  cold  sweat,  intense 
burning  pain  and  heat  at  the  epigastrium,  thirst  with  burning  in  the 
fauces  2:0.^  gullet,  and  exhatistive  purging  ;  the  features  are  more  or 
less  retracted  or  sunken,-  these  symptoms  terminating  in  collapse  and 
death,  or  slow  convalescence  and  recovery  with  a  crippled  stomach. 
If  death  be  delayed  some  hours,  marked  nephritic  symptoms  appear. 

A  diagftosis  of  the  character  of  the  poison  swallowed  is  often 
afforded  by  the  stain  of  the  lips,  face,  and  mucous  membrane,  to  wit: 
siilphuric  acid,  blackish  eschar  ;  nitric  acid,  yellowish  eschar ;  caustic 
potash,  spreading  widely  and  softening  the  tissues  ;  corrosive  subli- 
mate, whitish  or  glazed  ;  carbolic  acid,  white  and  corrugated  ;  chro- 
mic acid,  yellowish-white,  changing  to  grayish  brown. 

Prognosis.  Very  grave.  Many  perish  from  shock,  and  the  de- 
struction of  the  mucous  membrane  of  the  stomach,  which  prevents 
nourishing.  Early  treatment  when  no  perforation  of  the  walls  of  the 
stomach  has  occurred  and  recovery  is  possible,  the  organ  being  ever 
after  much  weakened. 

Treatment.  At  once,  hypodermic  injection  of  morphince  sulphas, 
repeated  as  often  as  indicated. 

Vomiting  should  be  encouraged  by  the  free  use  of  demulcents. 

If  the  case  be  seen  within  a  short  period  of  the  swallowing  of  the 
poison,  the  proper  antidote  should  be  used,  but  if  some  hours  have 
elapsed,  it  is  useless. 


80 


PRACTICE    OF    MKDICINK. 


Irritant  and  Corrosivk  Poisons. 


Poison. 
Acids,  mineral  or  oxalic. 

Ammonia  (  "  houseliold 
ammonia "  )  or  lini- 
ment. 

Arsenic. 


Carbolic  acid. 

Chromic  acid. 

Corrosive  sublimate. 
Iodine. 

Phosphorus  (matches). 

Silver  nitrate. 
Soda,    or    "caustic    pot- 
ash."    "  Lye." 

Sulphate  copper. 


Antidotes. 

Chalk,  magnesia  (plaster  of  wall  in  emergency), 
solution  carbonate  soda,  emollient  drinks,  fixed 
oils. 

Vinegar  mixed  with  a  bland  oil,  and  sustain 
heart  will)  strychnia. 

Moist  peroxideof  iron  (olitained  from  perchloiideof 
iron  and  calcined  magnesia)  or  the  ferri  oxidum 
hydratum,  U.  S.  P.,  charcoal,  ammonia  to  nos- 
trils. 

Castor  oil,  olive  oil,  and  the  suljihate  of  magne- 
sium or  sodium  as  a  chemical  antidote.  Prompt 
stimulation. 

Acetate  of  iron,  ten  per  cent,  solution  nitrate  sil- 
ver, forming  insoluble  silver  chromale. 

Albumen,  white  of  egg  (four  grains  sublimate 
require  white  of  one  egg),  flour,  milk. 

Demulcent  drinks,  starch  or  flour  in  water. 

Magnesia,  tur])entine,  demulcents.  Wash  stom- 
ach by  use  of  stomach  tube  or  pump  and  warm 
water,  afterward  using  Epsom  salts. 

Solution  common  salt  in  demulcent  drinks. 

Olive  oil,  demulcents,  vinegar,  lemon  juice,  and 
hypodermical!y  stimulants. 

Albumen  or  white  of  egg,  stomach  pump,  and 
wash  stomach  with  soap  water. 


Ice,  internally  and  externally,  gives  great  relief.  The  stomach 
should  be  washed  out  with  the  stomach  tube  or  pump,  thereby  re- 
moving any  remaining  poison,  which  at  the  same  time  acts  as  a 
sedative  to  the  inflamed  membrane.  Bismuthi  stibniiras,  gr.  xx-xxx 
(1.3-2  Gm.)  every  hour  or  two,  is  beneficial. 

Milk  and  lime-water  \%  the  only  food  that  should  be  given  by  the 
stomach,  ene7naia  being  used  to  support  the  system.  Strychnines  sul- 
phas and  atropincB  sulphas  hypodermically  to  sustain  the  heart  and 
nervous  system. 


DISEASES   OF   THE   STOMACH.  81 

CHRONIC  GASTRIC  CATARRH. 

Synonyms.  Chronic  gastritis  ;  chronic  dyspepsia  ;  drunkards' 
dyspepsia. 

Definition.  A  chronic  catarrhal  inflammation  of  the  stomach, 
with  thickening  of  the  coats  and  atrophy  of  the  gastric  glands ;  char- 
acterized by  tenderness  over  the  epigastrium,  impaired  appetite,  pain- 
ful and  imperfect  digestion,  thirst,  and  great  depression  of  spirits  or 
melancholia. 

Van  Valzah  describes  three  forms  of  chronic  gastritis — viz.  :  (i) 
Gastritis  catarrhalis  chronica,  or  chronic  asthenic  gastritis;  (2)  gas- 
tritis glandularis  proliferans,  or  chronic  hypersthenic  gastritis  ;  (3) 
gastritis  glandularis  atrophicans,  or  progressive  atrophy  of  the  gastric 
glands. 

Causes.  Repeated  attacks  of  acute  gastric  catarrh  ;  habitual  and 
excessive  use  of  spirituous  liquors,  tea,  coffee,  and  the  free  use  of  ice- 
water  during  and  between  meals ;  improperly  prepared  and  unsuit- 
able food  ;  irregularity  of  meals  and  imperfect  mastication  ;  excessive 
tobacco-chewing  ;  malaria;  disease  of  the  heart,  lungs,  pleura, liver, 
or  kidneys,  producing  chronic  congestion  of  the  stomachic  vessels  ; 
cancerous  or  other  degenerative  diseases  of  the  stomach. 

Pathological  Anatomy.  The  mucous  membrane  is  of  a  brown- 
ish or  slate  color,  elevated  into  ridges  from  hypertrophy,  the  result  of 
constant  congestion  ;  the  peptic  glands  first  increase  in  size,  then  un- 
dergo granular  change,  atrophy  of  their  cells  resulting.  The  mucous 
membrane  is  covered  with  a  thick,  alkaline,  tenacious  mucus.  Ewald 
describes  the  minute  anatomy  as  that  of  a  parenchymatous  and  inter- 
stitial inflammation,  which  may  lead  to  such  widespread  degenera- 
tion of  the  glandulair  elements  that  ultimately  scarcely  a  trace  of 
secreting  tissue  remains.  These  changes  may  affect  the  entire  organ 
or  be  limited  to  portions  of  the  stomach. 

Symptoms.  The  persistent  and  manifold  symptoms  of  indiges- 
tion, varying  somewhat  with  the  extent  of  the  mucous  surfaces  and  se- 
creting glands  involved,  are  the  first  indications  of  the  disease,  such 
as  loss  of  appetite,  disagreeable  feeling  oi gnawing  and  at  \.\n\ts  full- 
ness in  the  stomach,  tenderness  at  the  epigastrium,  but  slightly  influ- 
enced by  eating,  prominence  of  the  epigastrium,  from  distention  by 
decomposing  gases,  occasional  nausea  and  vomiting  after  meals,  of 
undigested  food,  or,  when  the  stomach  is  empty,  of  colorless  fluid,  A 
6 


82  PRACTICE    OF    MEDICINE. 

colorless  vomit  joined  to  symptoms  of  long-continued  indigestion  is 
always  very  characteristic  of  chronic  gastritis.  Drunkards  suffer 
from  an  early  morning  vomit  consisting  of  glairy  mucus  and  saliva 
swallowed  during  sleep,  raised  only  after  great  retching.  The  ione^ue 
is  usually  heavily  coated,  although  it  may  be  clean  ;  thirst  is  often 
constant,  water  and  more  frequently  stimulants  being  craved  ;  burn- 
ing at  the  pit  of  the  stomach  and  under  the  sternum  (heartburn)  is 
very  common;  fiain,  sharp  and  diffused,  after  eating;  the  bowels  are 
constipated,  the  urine  high-colored  and  contains  an  excess  of  phos- 
phates or  urates,  or  exhibits  crystals  of  oxalate  of  lime.  In  advanced 
cases  the  circulation  is  feeble,  there  is  depression  of  spirits  amount- 
ing in  some  instances  to  delusional  melancholia;  sleeplessness  is 
persistent,  and  occasionally  there  are  attacks  of  vertigo  (stomachic 
vertigo),  which  greatly  alarm  the  patient.  All  of  these  symptoms  re- 
sult from  either  a  deficient  secretion  of  the  gastric  juice  or  from  a  less- 
ened proportion  of  hydrochloric  acid  in  the  juice  secreted,  and  also 
from  the  excessive  mucus  and  from  diminished  peristalsis  of  the  stom- 
ach, such  morbid  conditions  favoring  the  fermentation  and  decom- 
position of  the  food.  Follicular  pharyngitis  of  an  aggravated  type 
adds  to  the  general  distress  of  the  patient.  The  imperfect  digestion 
causes  more  or  less  loss  of  flesh,  the  fat  disappearing,  the  muscles  re- 
laxed and  the  skin  dry,  harsh,  and  of  a  dirty-pale  color,  and  not  in- 
frequently eczema  and  other  cutaneous  diseases  develop. 

Diagnosis.  Chronic  gastritis  is  associated  with  so  many  chronic 
diseases  that  a  correct  diagnosis  is  of  great  importance.  Among  the 
affections  likely  to  lead  to  error  in  diagnosis  are  gastric  ulcer,  gastric 
cancer,  gastric  dilatation,  cerebral  vertigo,  cardiac  disease,  and  dis- 
ease of  the  kidneys  and  liver. 

Prognosis.  Complete  recovery  is  hardly  to  be  expected,  but 
great  amelioration  of  symptoms  occur  and  with  guarded  diet  and 
mode  of  life  good  health  may  be  enjoyed  for  many  years.  It  is  usually 
a  disease  of  middle  life. 

Treatment.  The  first  indication  is  the  correction  of  the  ittdiges- 
tion,  which  is  usually  the  most  pronounced  and  distressing  symptom  ; 
this  is  accomplished  by  carefully  regulating  the  amount  and  charac- 
ter of  the  food  used,  avoiding  fatty,  saccharine,  and  starchy  articles  or 
highly  seasoned  food  or  stimulants.  A  milk  diet  is  beneficial,  to 
which  may  be  added  beef  in  small  amounts,  eggs,  oysters,  and  a  few 
fresh  green  vegetables.     If  beef  is  allowed,  it  had  better,  for  a  time, 


DISEASES   OF  THE  STOMACH.  83 

be  in  the  form  of  "Salisbury  steaks  " — ^made  of  lean  beef  shaped  into 
flattened  cakes  and  broiled.  This  or  whatever  other  articles  of  diet 
are  allowed  to  be  taken  an  hour  or  more  after  sipping  slowly  a  half 
pint  (237  Cc.)  of  water,  at  iio°-i5o°.  The  hot  water  should  also  be 
taken  before  retiring. 

The  second  important  symptoms  to  correct  are  the  constipation, 
which  is  often  most  obstinate,  and  clearing  the  stomach  of  the 
tenacious  mucus  which  neutralizes  whatever  gastric  juice  is  secreted. 
Appropriate  purgatives  are  the  natural  mineral  waters,  such  as  Bed- 
ford Water,  Saratoga,  Hunyadi  Janos,  or — 

R.     Magnesii  sulph., gr.  Ix-cxx  4.-8.  Gm. 

Sodii  et  potass,  tart., gr.  xxx-lx  2.-4.  Gm. 

Acid,  tartaric, gr.  xx  1.3       Gm.         M. 

Dissolved  in  a  glass  of  water  and  drank,  effervescing,  an  hour  before  break- 
fast. 

An  excellent  purgative  and  promoter  of  stomachic  peristalsis 
is : 

R.     Ext.  cascaras  sagradae  fld.,  .    .    .    .  f.^j  30.  Cc. 

Glycerini, f^ss  15.  Cc. 

Tinct.  nucis  vomicae, f^ss  15.  Cc. 

Aq.  chloroformi  vel  inf.  glycyrrh.,  fgj  30.  Cc.  M. 

SiG. — One  to  two  teaspoonfuls  after  meals,  well  diluted. 

For  the  purpose  of  cleansing  the  stomach  of  the  tenacious  mucus 
as  well  as  for  its  stimulating  action  on  the  glands,  lavage  or  irrigation 
of  the  stomach  with  lukewarm  water  is  valuable.  The  water  can  be 
medicated  with  a  solution  of  salt,  or  sodii  bicarbonas  or  acidum 
boricum.  Ewald  considers  the  morning,  on  an  empty  stomach,  the 
preferable  hour  for  the  practice  of  stomach  washing. 

Those  patients  who  object  to  lavage  obtain  relief  from  the  system- 
atic drinking  of  one-half  to  one  pint  (237-475  Cc.)  of  hot  water  an 
hour  before  meals,  as  mentioned  above. 

For  the  irritable  condition  of  the  mucous  membrane,  associated 
with  the  poor  appetite  and  slow  digestion,  good  results  are  reported 
from  stroniii  bromidmn,  gr.  xv  (i  Gm.),  well  diluted,  before  meals. 

For  the  morbid  condition  of  the  mucous  membrane  may  be  used, 
liq.  potassii  arsenitis,  Tt\,j-ij  (0.06-0.12  Cc),  before  meals,  or  bismuth, 
subnit.,  gr.  x-xx  (0.65-1.3  Gm.),  on  a  comparatively  empty  stomach, 
one  hour  before  or  two  or  three  hours  after  meals  ;  it  may  at  times  be 


84  PRACTICE    OF    MEDICINE. 

combined  with  soiiii  bicarbonas.     The  following  combination  often 
gives  great  comfort  for  a  long  time  if  the  diet  is  regulated  : 

li.     Sod ii  bicarb.,       5  iv  15.  Gm. 

Bismutli.  subnit. , Xvj  24.  Gm. 

Aqu:i;  chloroformi, f  5  ''J  9°-  ^'^• 

M.  et  atJde 

Aqu.x  lauro-cerasi, f  o ''J  9°-  ^^• 

Stryclinina;  sulph., gr.  j  .065  Gm.         M. 

SiG. — Two  teaspoonfuls  atmeal-lime  in  a  little  water. 

Argentinitras,  gr.  ^  (0.016  Gm.),  or  argenti oxidiiin,  gr.  ss-j  (0.032- 
0.065  Gm.),  in  pill,  before  meals,  or  acidittn  hydrochloricion  diiuluin, 
TTLx-.w  (0.6-1  Cc),  in  water,  before  meals,  are  useful  remedies. 

Pain  is  so  severe  in  some  cases  that  resort  must  be  had  at  times  to 
opium  or  belladoftna  in  small  doses,  after  meals.  Emplastruin  bella- 
donna; over  the  stomach  is  useful.  Cocaince  hydrochloras,  gr.  Yd 
(o.oi  Gm.),  is  also  recommended. 

To  aid  digestion,  acids,  pepsinum,  pancreatinum,  papoid,  and 
bitters  are  of  value,  the  following  being  an  excellent  prescription : 

R.     Pepsin!  (cryst.), gi"- Ix  4.         Gm. 

Acid,  hydrochlorici  dil.,    .    .    .    .  f^iv  15.         Cc. 

Glycerini, f^'v  15.         Cc. 

Strycbnin?e  sulph., gr.  ss  .032  Gm. 

Aqun;  chloroformi,      .    .    q.  s.  adf5iij  ad  90.         Cc.  M. 

SiG. — One  teaspoonful  at  mealtime  in  a  little  water. 

Rest  of  the  body  and  mind  is  almost  as  important  as  rest  of  the 
stomach. 


GASTRIC  ULCER. 

Synonyms.  Peptic  ulcer ;  chronic  gastric  ulcer ;  perforating 
ulcer. 

Definition.  A  solution  of  continuity,  involving  the  mucous 
membrane  and  one  or  more  layers  of  which  the  walls  of  the  stomach 
are  composed ;  characterized  by  gastric  pain,  disorders  of  digestion, 
and  vomiting  of  blood. 

Causes.  There  'is  no  generally  accepted  view  of  the  etiology. 
Van  Valzah  truthfully  says,  "  Ulcer  is  not  a  disease  with  a  single 
cause  and  one  mode  of  genesis."     Ewald  attributes  it  mainly  to  an 


DISEASES   OF  THE  STOMACH.  85 

"altered  composition  of  the  blood,  and  the  resulting  insufficient 
nourishment  of  the  cells."  Riegel  claims  that  the  ulcer  is  due  to  a 
self-digestion  of  the  stomach  at  a  limited  spot,  and  it  is  certainly 
more  than  a  coincidence  that  in  ulcer  the  gastric  juice  is  nearly 
always  hyperacid.  More  common  in  young  females  than  males. 
Anaemia  or  its  sequela  a  chief  factor ;  disorders  of  menstruation ; 
blows  over  the  epigastrium;  burns  of  the  integument;  syphilis; 
tuberculosis.  Virchow  claims  that  emboli  or  thrombi  form  in  the 
nutrient  gastric  arteries  which  have  lost  their  tonicity,  an  ulcer  form- 
ing at  the  point  of  obstruction. 

Pathological  Anatomy.  In  the  majority  of  cases  the  ulcer  is 
solitary.  The  posterior  wall  near  the  pylorus  is  the  most  frequent 
location. 

In  a  typical  case  there  is  a  circular  hole,  with  sharp  borders  in  the 
serous  coat  of  the  stomach ;  the  loss  of  substance  is  greater  in  the 
mucous  membrane  than  in  the  muscular  coat,  and  greater  in  this 
than  in  the  serous  coat,  so  that  the  ulcer  looks  like  a  shallow  funnel, 
the  apex  at  the  outer  wall,  the  base  at  the  inner  wall  of  the  stomach  ; 
it  is  first  round,  growing,  becomes  elliptical,  bulging  at  portions,  be- 
coming irregular ;  size,  from  X~X  1"^^^  in  diameter.  When  the 
ulcer  heals  before  all  the  coats  are  perforated,  a  distinct  cicatrix 
marks  the  location.  During  its  progress  nutrient  vessels  are  eroded, 
causing  profuse  hemorrhage.  Chronic  gastric  catarrh  complicates 
the  majority  of  cases. 

Symptoms.  More  or  less  prominent  symptoms  of  indigestion. 
Pain  constant  at  the  "  pit  of  the  stomach,"  increased  by  taking  food, 
especially  of  an  irritating  character,  the  pain  often  felt  in  the  back, 
of  a  burning,  gnawing  character.  Tenderness  at  one  or  more  points, 
extending  from  the  front  to  the  back.  Vomiting  is  almost  as  constant 
as  pain,  coming  on  soon  after  eating  if  the  ulcer  is  at  the  cardiac  ori- 
fice, an  hour  or  so  after  if  it  is  located  at  or  near  the  pylorus.  Rejected 
matter  may  be  undigested  or  partly  digested  food,  or  simply  acrid 
mucus.  Vomiting  of  blood  in  large  quantities  and  arterial  in  color  is 
almost  diagnostic  of  gastric  ulcer;  the  blood  may  be  dark  in  color  if 
it  has  remained  in  the  stomach  some  time  before  being  rejected. 

Severe  and  frequent  attacks  of  gastralgia  may  add  to  the  suffering 
of  the  patient.  The  general  condition  of  the  patient  is  not  significant, 
some  being  greatly  debilitated,  while  in  others  the  nutrition  is  but 
little  deranged. 


86  PRACTICE    OF    MEDICINE. 

* 

Duration.  The  ulcer  is  slow  in  forming,  and  runs  a  very  chronic 
course,  an  average  duration  being,  perhaps,  about  a  year.  Cases  are 
recorded  in  which  the  disease  has  suddenly  developed  and  terminated 
hy  perforation,  peritonitis,  and  death  within  two  weeks,  but  such  in- 
stances are  rare. 

Diagnosis.  Duodenal  ulcer  presents  symptoms  so  akin  to  those 
of  gastric  ulcer  that  a  differential  diagnosis  is  impossible. 

Chronic  gastritis  is  often  confounded  with  gastric  ulcer ;  the  dis- 
tinctive points  are  :  absence  of  vomiting  of  blood,  no  localized  con- 
stant pain  aggravated  by  food,  and  no  tenderness  in  the  back  ;  while 
the  symptoms  of  indigestion  are  marked  and  persistent,  with,  as  a 
rule,  a  history  of  spirit  drinking,  and  the  age  of  the  patient — middle 
life  ;  ulcer  in  the  young. 

The  points  of  distinction  between  gastric  cancer  and  gastralgia  will 
be  pointed  out  when  considering  those  affections. 

Prognosis.  Gastric  ulcer  is  a  dangerous  disease,  and  the  prog- 
nosis should  be  very  guarded.     Recoveries  are  frequent. 

The  dangers  r^ixt.  perforation,  peritonitis,  ox  fatal  hemorrhage. 

Treatment.  Give  the  stomach  as  complete  a  rest  as  possible; 
this  is  accomplished  by  rectal  alimentation,  or  when  it  cannot  be 
carried  out,  an  exclusive  viilk  diet,  adding  lime-water  to  enable  the 
stomach  to  better  retain  the  milk,  or  a  strictly  skimmed-milk  diet,  to 
which  may  also  be  added  lime-water  ;  the  amount  of  milk  should  be 
one  or  two  ounces  every  two  hours.  Rest  in  bed  and  keeping  the 
stomach  empty  by  rectal  feeding  give  the  most  favorable  condition 
for  the  healing  of  the  ulcer.  If  a  severe  hemorrhage  occurs  and  col- 
lapse is  imminent,  a  pint  (475  Cc.)  of  warm  physiological  solution  of 
common  salt  (oj  or  4  Gm.)  to  one  pint  (475  Cc.)  should  be  slowly 
introduced  into  the  rectum.  Additional  amounts  of  the  salt  solution 
may  be  injected  into  the  subcutaneous  cellular  tissues.  At  the  same 
time  sustain  the  heart  by  hypodermic  injections  of  strychnines  sulphas, 
nitroglycerinuni,  and  ammonia. 

To  correct  hyperacidity  use  a  combination  of  sodii  bicarbonas  and 
magnesia  calcined,  in  large  doses  after  each  feeding,  if  stomach  ali- 
mentation is  allowed,  and,  if  not,  every  four  hours.  Belladonna  is  a 
valuable  drug  for  excessive  acid  secretion. 

For  pain,  small  doses  of  morphincE  sulphas  should  be  used  as 
needed. 

For  hemorrhage,  hypodermic  injections  of  ergota  are  most  reliable. 


DISEASES   OF  THE  STOMACH.  87 

Plumbi  acetas,  gr.  j-iij  (0.065-0.2  Gm.),  arrests  the  bleeding  and 
exercises  a  favorable  influence  over  the  ulcer.  An  ice-cap  or  bag 
over  the  epigastrium  is  most  valuable. 

For  the  ulcer,  liquor  potassii  arsenitis,  Ttij-ij  (0.06-0.13  Cc),  every 
five  hours,  has  given  excellent  results  in  several  cases  treated  by  the 
author;  bismuthi  subnitras,  gr,  xx-xxx  (1.3-2  Gm.),  combined  with 
sodii bicarbonas,  gr.  v  (o  32  Gm.),  three  times  a  day,  often  does  well; 
argenti  nitras,  gr.  X~K  (0.016-0.022  Gm.),  every  four  hours,  or 
argenti  oxidum,  gr.  ss  (0.032  Gm.),  every  four  hours,  are  at  times 
beneficial. 

For  the  associated  zvi-s-rmz.,  ferrum  and  arsenicum,  alone  or  com- 
bined, are  indicated.  Ferri  albuminate  would  seem  to  be  particularly 
indicated,  or  the  following  : 

R.     Pulv.  ferri  albuminatis, gr.  ij  .13    Gm. 

Sodii  arseniat., gr.  ^V  -003  Gm.         M. 

Ft.  pil.  or  capsule,  taken  three  or  four  times  daily. 

The  bowels  must  be  kept  soluble. 

If  perforation  and  peritonitis  result,  full  doses  of  opium  are  indi- 
cated.    Surgical  aid  is  indicated  for  the  perforation. 


GASTRIC  CANCER. 

Synonyms.     Cancer  of  the  stomach ;  gastric  carcinoma. 

Definition.  A  peculiar  malignant  grov/th,  occurring  for  the  most 
part  at  the  pyloric  extremity  of  the  stomach,  making  constant  pro- 
gress, destroying  the  gastric  tissues  and  infecting  the  lymphatic 
glands ;  characterized  by  disorders  of  digestion,  pain,  vomiting, 
marked  anaemia,  and  terminating  in  all  cases  by  the  death  of  the 
patient. 

Cause.  Hereditary.  Develops  after  forty  years,  for  the  most 
part.  The  question  of  a  cancer  germ  is  gaining  ground.  Twice  as 
many  cancers  occur  in  women  as  in  men. 

Pathological  Anatomy.  Cancer  of  the  stomach  is  the  most 
common  form  of  cancer.  It  is,  as  a  rule,  a  primary  cancer.  The 
variety  is  most  commonly  the  scirrhus,  next  in  frequency,  medullary, 
the  least  frequent,  colloid.     As  regards  the  location,  eighty  per  cent. 


88  PRACTICE    OF    MEDICINE. 

occur  at  \.\it  pylorus.  Those  portions  of  the  stomach  remote  from  the 
cancer  are  normal  or  comparatively  healthy. 

It  originates  usually  in  the  tubules,  rajjidly  infiltrating  the  remain- 
ingtissues,  thickening  everywhere  as  it  progresses,  and  either  remains 
a  hard  nodulated  mass  or  undergoes  ulceration.  The  hard  nodulated 
growth  at  the  pylorus  constricts  the  orifice,  resulting  in  dilatation  of 
the  stomach.  The  lymphatic  glands  adjacent  to  the  stomach  are 
infiltrated,  secondary  cancers  resulting.  Ulceration  into  an  artery 
causes  hemorrhage  into  the  peritoneum,  resulting  in  local  peritonitis. 

Complications.     Fatty  heart ;  thrombosis  ;  tuberculosis. 

Symptoms.  The  development  of  gastric  cancer  is  insidious, 
with  indigestion,  progressive  in  character,  associated  with  marked 
acidity ,  flatulency ,  and  a  fetid  breath. 

The  majority  of  cases  have  vomiting,  occurring  immediately  after 
eating,  if  the  disease  is  at  the  cardiac  orifice,  and  some  hours  after  if 
located  at  the  pylorus;  if  much  dilatation  of  the  stomach  develop, 
the  vomiting  occurs  some  days  after  eating.  The  rejected  matter  is 
food  in  various  stages  of  digestion,  associated  frequently  with  black 
grumous  masses  of  altered  blood  and  tissues.  Hematemesis  is  fre- 
quent, rarely  profuse,  usually  oozing  of  blood  altered  into  a  dark 
brown  or  black  color — "coffee  ground"  vomit  or  the  oozing  blood 
passes  into  the  intestinal  canal,  causing  tary  stools. 

Absence  of  hydrochloric  acid  in  the  stomach  is  a  very  constant 
observation  in  gastric  cancer.  Boas  and  Stewart  (D.  D.),  in  1895, 
found,  by  the  use  of  the  test-meal  (flour  soup),  that  lactic  acid  was 
always  present  in  gastric  cancer,  and  they  were  unable  to  find  this 
acid  in  any  other  stomach  condition. 

Pain,  marked  and  constant,  dull,  heavy,  increased  by  pressure  or 
food,  seldom  lancinating.  Marked  aficsinia  and  emaciation  soon 
occur,  the  surface  having  an  earthy  or  fawn  color.  QLdema  of  the 
ankles  is  an  early  diagnostic  symptom  in  carcinoma  of  the  stomach, 
often  occurring  as  early  as  the  third  month,  and  may  progress  to  a 
general  anasarca.  A  tumor  is  found  in  three-fourths  of  the  cases, 
occupying  the  epigastric  region,  not  tnovingwith  inspiration.  As  the 
carcinoma  progresses,  the  lymphatic  glands  enlarge,  particularly  the 
supra-clavicular  and  inguinal  glands.  Jaundice  frequently  occurs, 
and  the  liver  is  enlarged.  The  urine  often  contains  albumin.  An 
irregular  temperature  occurs  in  some  patients. 

The  duration  of  the  disease  is  about  one  year,  the  patient  dying 


DISEASES    OF   THE   STOMACH.  89 

from  exhaustion,  peritonitis,   or   hemorrhage,   the   mind   clear  but 
despondent. 

Diagrnosis.  The  continuous  absence  of  free  hydrochloric  acid 
and  the  presence  of  lactic  acid  in  the  stomach  are  diagnostic  signs 
of  great  value  in  determining  the  probable  existence  of  gastric  cancer. 
It  is  possible  to  make  a  positive  diagnosis  by  study  of  the  rational 
symptoms  and  the  aid  of  the  X-rays. 

Chronic  gastric  catarrh  differs  from  gastric  cancer  in  the  absence 
of  a  tumor,  bloody  vomit,  characteristic  pain,  peculiar  color  of  the 
surface,  dropsy,  and  the  rapid  emaciation. 

Gastric  tilcer  differs  in  the  character  of  the  pain,  age  of  the 
patient,  large  amount  and  color  of  bloody  vomit,  the  absence  of  a 
tumor,  and  progressive  emaciation.  Still  the  diagnosis  is  often 
difficult. 

Abdominal  tumors  may  raise  the  question  of  a  gastric  cancerous 
tumor ;  the  points  of  distinction  are  the  characteristic  symptoms  of 
gastric  cancer,  and  that  abdominal  tumors,  especially  of  the  liver  and 
spleen,  the  ones  most  apt  to  cause  error  in  diagnosis,  are  influenced 
by  inspiration,  while  tu7nors  of  the  stomach  are  not  so  influenced. 
•^  When  a  scirrhus  of  the  pylorus  lies  upon  the  aorta,  a  pulsation  may 
be  communicated  to  it,  raising  the  question  of  aneurism  of  the 
abdominal  aorta,  but  the  expansile  pulsation  of  aneurism  (Corrigan's 
sign)  is  wanting,  as  are  the  other  symptoms  of  the  affection,  and  if 
the  patient  is  made  to  rest  upon  his  hands  and  feet,  the  stomachic 
tumor  falls  away  from  the  aorta  and  pulsation  ceases. 

Mikulicz  claims  that,  by  the  use  of  his  gastroscope,  regular  rhyth- 
mical motions  can  be  seen  when  the  pylorus  is  not  the  seat  of  cancer, 
and  that  such  movements  are  absent  when  it  is  the  seat  of  cancer. 

Prognosis.  Unfavorable.  Internal  medication  offers  no  hope, 
the  patient  usually  succumbing  from  starvation. 

Gastric  carcinoma  occurring  under  thirty  years  of  age  is  rapidly 
fatal,  not  conforming  to  the  usual  symptoms  as  seen  later  in  life  ;  the 
characteristic  cachexia  is  commonly  absent  and  hgematemesis  is  rare. 

Treatment.  We  possess  no  means  of  arresting  the  disease, 
although  it  is  but  fair  to  mention  that  in  Germany  condurango  in  the 
form  of  decoction  is  recommended  as  a  specific  in  gastric  cancer. 
I  have  faithfully  used  the  fluid  extract  with  some  benefit  for  the 
accompanying  gastritis,  but  without  effect  on  the  tumor. 

Six  operations  have  been  recommended  for  the  relief  of  stenosis  of 


90  PRACTICE    OF    MEDICINE. 

the  pylorus:  Ibt.  Pylorectomy ;  2d.  Gastro-enterostomy  ;  3d.  Gas- 
trectomy ;  4ih.  Gastrostomy  ;  5th.  Diiodenoslomy  ;  61I1.  Digital  di- 
vulsion  of  the  pylorus.  Professor  Billroth  has  excisiU  the  pylorus, 
thereby  prolonging  life  ten  months  in  one  case  and  five  years  in  an- 
other. 

During  the  past  year  (1898)  two  successful  operations  for  the  re- 
moval of  the  entire  stomach  have  been  reported,  both  patients  being 
alive  some  weeks  after. 

For  acidity  diwd.  ft-for  of  (he  breath,  acidiim  carbolicum,  gr.  X~/^ 
(0.016-0.022  Gm.),  or  carbo  animalis  piirificatus,  gr.  x-xxx  (0.65-2 
Gm.),  affords  some  relief. 

For  voifiititig  diX\d pain,  bismuth  and  opium,  or  lavage  or  the  wash- 
ing out  of  the  stomach.  The  lavage  should  be  performed  an  hour 
before  breakfast,  followed  in  half  an  hour  with : 

K.     Strychnincc  suli)h., gr.  ss  .032  Gm. 

Acid,  hydrocblor.  dil., fn'^'  ^5-         Cc. 

Inf.  condurango,     .    .    .     q.  s.  ad  f  5  viij  ad  240.         Cc. 
M.  et  ft.  taljlespoonful  before  meals,  diluted. 

Y or  pain,  morphina,  or  the  following,  recommended  by  Osier  :        ^ 

R.     Morphince  sulph., S^-  ^i  .008  Gm. 

Sodii  bicarb., gr.  v  .3       Gm. 

Bismuth,  subnit., gr-  x  .6       Gm.         M. 

SiG. — Repeated  p.  r.  n. 

Avoid  stimulants. 


GASTRIC    DILATATION. 

Synonyms.  Gastrectasis ;  pyloric  obstruction  ;  pyloric  stenosis 
Definition.  An  abnormal  increase  of  the  cavity  of  the  stomach, 
with  the  walls  either  hypertrophied,  or  decreased  in  thickness;  char- 
acterized by  pronounced  indigestion,  vomiting  of  partly  digested  and 
partly  decomposed  food  at  intervals  of  a  day  or  two,  and  noisy  mov- 
ing of  flatus  within  the  abdomen  (borborygmus). 

Causes.  Most  common  cause  a  stricture  of  the  pylorus,  the  result 
of  cancer  ;  pressure  of  tumor  against  the  pylorus,  preventing  exit  of 
stomachic  contents.  Loss  of  muscular  tone,  occurring  in  anaemia. 
Prof.  Bartholow  cites  cases  resulting  in  excessive  beer-drinkers,  who 
drank  thirty  to  forty  glasses  of  beer  habitually,  every  day. 


DISEASES   OF  THE  STOMACH.  91 

Pathological  Anatomy.  When  obstruction  exists  at  the  pylo- 
rus, the  whole  organ  is  dilated,  with  hypertrophy  of  the  muscular  layer 
of  the  stomach.  In  dilatation  without  pyloric  obstruction,  the  muscu- 
lar layer  is  thinner  than  normal,  paler  in  color,  and  presents  signs  of 
fatty  degeneration  ;  the  mucous  membrane  is  also  pale,  thin,  and 
without  rugae. 

Symptoms.  Those  of  the  disease  producing  the  obstruction  plus 
those  of  obstinate  chronic  gastric  catarrh,  with  characteristic  vomiimg  ; 
the  cavity  having  a  greatly  increased  capacity,  large  accumulations 
take  place,  which  are  rejected  every  day  or  two,  partly  digested  and 
partly  decomposed.  Regurgitation  of  partly  digested  aliment,  acrid, 
acid,  and  offensive,  is  very  common.  Bowels  constipated,  the  stools 
hard  and  dry. 

Physical  signs  of  gastric  dilatation  are :  on  inspection,  abnormal 
prominence  of  the  whole  epigastric  region,  with  a  tumor  in  \\\& pyloric 
region  which  seems  to  be  connected  with  the  stomach ;  percussion, 
if  empty,  tympanitic  note  extending  to  or  below  the  umbilicus, 
having  a  metallic  quality  ;  if  the  stomach  be  filled,  high-pitched  flat 
note  ;  auscultaiio?t,  splashing  and  rumbling  sound,  the  succussion 
sound  being  distinct  if  the  body  be  shaken. 

Diagnosis.  Copious  vomiting  of  food  partly  digested,  once  in 
twenty-four  hours  or  less  often,  epigastric  distress  and  pain  resulting 
from  foul-smelling  and  acid  eructations  and  from  obstinate  constipa- 
tion. And  on  percussion  the  tympanitic  note  of  the  stomach  as  low 
or  lower  than  the  umbilicus,  with  some  dullness,  maybe  due  to  food  or 
liquid  in  stomach. 

If  a  doubt  then  exist,  give  large  amount  of  food  and  note  dullness, 
or,  what  is  not  so  pleasant,  sodii bicarbonas ,  gr.  xv  (i  Gm.),with  acidum 
tartaricujn,  gr.  xx  (1.3  Gm.),  and  the  tympanitic  outline  of  the  stomach 
will  be  evident. 

Dr.  Leonard  has  determined  the  presence  of  gastric  dilatation  by 
the  X-ray  and  use  of  bismuth  solution  to  produce  a  shadow  in  stomach. 

Penzoldt's  modification  of  Piorry's  method  of  determining  gastric 
dilatation  is  to  withdraw  the  contents  of  the  stomach  by  means  of  the 
oesophageal  tube  and  then  refilling  the  stomach  with  fluid.  By  noting 
the  lower  limit  of  percussion  dullness  thus  produced,  the  lower  bor- 
der of  the  stomach  can  be  accurately  determined. 

Treatment.  Regulated  diet.  Restrict'the  use  of  fluids,  using  a 
"dry  diet"  exclusively.  * 


92  PRACTICE    OF    MEDICINE. 

If  ihe  result  of  pyloric  stenosis,  one  of  the  operations  mentioned 
for  pyloric  cancer  may  be  indicated. 

Regardless  of  the  cause,  washing  out  the  stomach  with  the  stomach 
tube  every  day  or  two,  gives  relief,  and,  if  no  stricture  be  present, 
administer  strychniti(e  sulphas  or  mix  vomica,  and  very  favorable 
results  may  follow. 

GASTROPTOSIS. 

Definition.  A  displacement  of  the  stomach  downward,  associ- 
ated with  prolapse  of  the  bowel  (enteroptosis  or  Gienard's  disease) 
and  prolapse  of  the  kidney  (nephroptosis). 

Causes.  Relaxed  condition  of  the  abdominal  walls  due  to 
impaired  development  or  loss  of  tension,  causing  improper  intra- 
abdominal pressure;  wearing  corsets  or  other  tight,  unyielding  gar- 
ments ;  occupations  favoring  stooping  posture,  leading  to  decreased 
tension  of  the  abdominal  walls,  such  as  seamstresses,  tailors,  and 
shoemakers,  or  other  sedentary  work;  frequent  pregnancies,  which 
stretch  the  abdominal  muscles. 

It  is  probable  that  there  exists  a  predisposition  to  imperfect  devel- 
opment of  abdominal  and  other  muscles,  or  their  early  loss  of  tension 
with  wasting. 

More  common  in  women  than  men,  as  would  be  expected  from  a 
study  of  the  causes. 

Anatomical  Conditions.  The  transverse  colon  is  the  first 
organ  to  prolapse,  soon  followed  by  the  ascending  colon.  The 
stomach  is  tilted,  as  it  were;  its  lower  border  reaching  below  the 
umbilicus,  while  its  lesser  curvature  lies  between  the  ensiform  carti- 
lage and  the  umbilicus.  In  some  cases  the  pyloric  end  is  down  to  or 
below  the  umbilicus  without  as  much  prolapse  of  the  fundus.  The 
right  kidney  is  displaced  and  often  floating  or  movable.  The  left 
kidney  is  less  often  displaced. 

Any  or  all  of  the  conditions  named  may  be  associated  with  any  of 
the  organic  gastric  conditions. 

Symptoms.  Impaired  digestion  with  eructations  of  gases.  Dis- 
tress or  feeling  of  weight  after  eating,  often  amounting  to  intense 
pain.  Loss  of  flesh  with  marked  a«i?/«/a  and  «^«rrtj/^<?«:^  symptoms 
are  almost  characteristic  "of  the  gastric  and  intestinal  prolapse.  Con- 
stipation is  the  rule,  although  cases  with  diarrhoea  have  been  reported. 


DISEASES   OF  THE  STOMACH.  93 

Physical  phenomena.  In  the  standing  position  the  lower  part  of 
the  abdomen  projects  and  the  upper  part  sinks  in.  In  the  recumbent 
position  the  abdomen  shows  a  lateral  extension.  Aortic  pulsation  is 
frequent.  There  is  often  "a  ridge  lying  across  the  abdomen"  to  be 
determined  by  palpation.  Glenard  termed  this  ridge  the  "  corde- 
colique  transverse"  and  thought  it  was  due  to  a  prolapse  of  and 
partial  occlusion  of  the  transverse  colon.  Other  observers  think  it  is 
the  pancreas  that  is  felt  on  account  of  the  prolapse  of  the  transverse 
colon.  Inflation  of  stomach  often  detects  its  prolapsed  position  with 
a  lowered  gastric  splashing.  The  X  ray,  with  the  aid  of  the  bismuth 
solution  for  shadow,  will  determine  the  location  of  the  organ. 

Treatment.  Unless  surgery  can  give  aid,  medication  is  but  pal- 
liative. Abdominal  bandages  are  recommended,  but  seem  of  small 
use.    The  chief  indication  is  to  improve  the  general  health. 


GASTRIC  HEMORRHAGE. 

Synonyms.     Haematemesis ;  gastrorrhagia. 

Definition.  Gastric  hemorrhage  is  not,  strictly  speaking,  a  di\s- 
ea.se,  hut  a.  sympfom/  still,  vomiting  of  blood  occurs  under  such  a 
variety  of  conditions  that  a  separate  consideration  is  desirable. 

Causes.  Ulcer  of  the  stomach  ;  cancer  of  the  stomach  ;  cirrhosis 
of  the  liver ;  scurvy  ;  purpura ;  haemophilia  ;  hemorrhagic  malarial 
fever ;  congestion  of  the  liver  or  spleen  ;  cirrhosis  of  the  liver ; 
vicarious  at  menstrual  period  ;  yellow  fever ;  toxic  gastritis. 

Symptoms.  Added  to  the  symptoms  of  the  cause  of  the  hem- 
orrhage, are  a.  feeling  of  faintness  and  sinking  at  the  pit  of  the  storn- 
ach,  followed  by  the  ejection  of  blood  of  a  black,  grumous,  or  coffee- 
ground  appearance.  Rarely,  and  then  generally  in  gastric  ulcer,  the 
ejected  blood  may  have  a  bright  red  appearance,  the  gastric  juice  not 
having  had  time  to  act  upon  it.  If  the  amount  of  blood  escaping 
into  the  stomach  is  large,  blood  will  be  voided  by  stool. 

Diagnosis.  Hemorrhage  frotn  the  lungs  may  be  confounded 
with  gastric  hemorrhage.  In  the  former,  the  blood  is  red,  is  coughed 
up,  not  vomited,  and  is  associated  with  a  history  of  pulmonary  dis- 
ease. The  chief  point  of  distinction  between  pulmonary  hemorrhage 
and  the  vomiting  of  red  blood  is  that  in  the  former  you  can  discern 
rales  on  auscultating  the  chest,  and  they  are  absent  in  the  latter.    In 


94  PRACTICE    OF    MliDIClNK. 

hemorrhage  from  the  stomach  there  is  almost  invariably  food  mixed 
with  the  blood. 

Prognosis.  Depends  entirely  upon  the  cause,  the  most  unfavor- 
able being  the  result  of  either  gastric  ulcer,  cancer,  hepatic  cirrhosis, 
or  hiuniophilia. 

Treatment.  Complete  rest  in  bed.  /r^?,  internally  and  applied  in 
bladders  over  the  epigastrium  and  along  the  spine,  or  hot  water,  as 
hot  as  can  be  borne,  in  quantities  of  four  to  six  ounces  at  very  fre- 
quent intervals. 

Hypodermic  injections  of  jnorphince  sulphas  quiet  the  patient's  fear, 
and  at  the  same  time  have  a  constringing  effect  upon  the  vessels. 
Exiractum  ergoice  fluiditin  or  ergotin  hypodermically  after  the  patient 
is  quieted,  or  liquor  fcrri  subsulphatis,  Tr\j-v  (0.06-0.3  Cc),  well 
diluted,  by  stomach. 

Cases  resulting  from  congestion  of  the  liver  or  spleen  are  benefited 
by  saline  purgatives. 

Allow  no  food  by  the  stomach  for  several  days,  nourishing  the 
patient  by  rectal  alimentation. 

The  hemorrhage  controlled,  the  future  treatment  is  guided  by  the 
exciting  cause. 

GASTRALGIA. 

Synonyms.  Cardialgia ;  gastrodynia  ;  stomachic  colic  ;  spasm 
of  stomach  ;  neuralgia  of  the  stomach. 

Definition,  A  painful  condition  of  the  sensory  nerves  of  the 
stomach,  induced  by  various  sources  of  irritation  ;  characterized  by 
violent  paroxysms  of  gastric  pain  and  spasm,  associated  with  feeble 
cardiac  action,  and  symptoms  of  collapse. 

Causes.  The  affection  belongs  to  the  group  of  neuralgias.  The 
most  important  factor  in  its  causation  is  general  nervous  depression 
or  neurasthenia  ;  other  causes  are  gastric  cancer  or  ulcer,  malaria, 
rheumatic  or  gouty  diathesis,  syphilis,  ansemia,  and  certain  articles  of 
diet.  Occurring  in  chronic  nervous  affections,  the  so-called  "gastric 
crises." 

Symptoms.  Like  most  neuroses,  gastralgia  is  distinguished  by 
\\.sparoxys?nal  character.     Romberg  thus  describes  an  attack  : 

"  Suddenly,  or  after  a  feeling  of  pressure  at  the  praecordium,  there 
is  sQ\Qr&  griping  pain  in  the  stomach,  usually  extending  to  the  back, 


DISEASES   OF  THE  STOMACH.  95 

with  2.  feeling  of  faintness,  a  shrunken  countenance,  cold  hands  and 
feet,  and  an  intermittent  pulse .  The  pain  becomes  so  excessive  that 
the  patient  cries  out.  The  epigastrium  is  either  puffed  out,  hke  a  ball, 
or  retracted,  with  tension  of  the  abdominal  walls.  There  is  oken pul- 
sation in  the  epigastrium.  External  pressure  is  well  borne,  and  not 
unfrequently  the  patient  presses  the  pit  of  the  stomach  against  some 
firm  substance,  or  compresses  it  with  his  hands.  Sympathetic  pains 
often  occur  in  the  thorax,  under  the  sternum,  and  in  the  oesophageal 
branches  of  the  pneumogastric,  while  they  are  rare  in  the  exterior  of 
the  body. 

"The  attack  lasts  from  a  few  minutes  to  half  an  hour  or  longer; 
then  the  pain  gradually  subsides,  leaving  the  patient  much  exhausted; 
or  else  it  ceases  suddenly,  with  eructation  of  gas  or  watery  fluid,  or 
with  vomiting,  and  with  a  gentle,  soft  perspiration,  or  with  the  passage 
of  reddish  urine." 

Besides  such  severe  attacks,  we  often  see  padnful  sensations  in  the 
epigastrium,  of  various  degrees  of  intensity,  with  passing  faintness  or 
sinking  at  the  "  pit  of  the  stomach,"  associated  with  heartburn,  or 
pyrosis,  ending  with  sensation  of  hunger,  drowsiness,  and  a  free  dis- 
charge of  clear  urine  of  low  specific  gravity. 

Diagnosis.  From  myalgia  of  the  abdominal  tnuscles,  by  the  pain 
of  gastralgia  being  more  acute  and  lancinating,  accompanied  by 
nausea  and  vomiting  and  the  absence  of  tenderness  on  pressure. 

From  intercostal  neuralgia,  by  the  fact  that  in  this  affection  the  pain 
is  in  the  left  hypochondrium,  with  painful  spots  along  the  course  of 
the  nerve  trunk  and  at  the  spine,  and  absence  of  nausea  and 
vomiting. 

From  gastric  cancer,  by  the  age,  character  of  the  vomited  matter, 
constancy  of  the  pain,  the  cachexia,  emaciation,  and  the  tutnor. 

From  gastric  ulcer,  by  the  localized  pain  and  its  constancy,  with 
tenderness  and  vomiting  of  blood,  and  constant  dyspeptic  symptoms, 
which  is  not  the  case  in  gastralgia. 

From  hepatic  or  gall-stone  colic,  by  the  pain  being  to  the  right  of 
the  median  line  radiating  to  the  right  and  to  the  right  scapula  and 
shooting  toward  the  right  ilium  and  the  sclerotic  jaundice  after  an 
attack. 

Prognosis.  As  to  perfect  recovery,  unfavorable,  but  not  danger- 
ous to  life.  A  chronic  affection,  in  that  attacks  are  prone  to  return 
from  time  to  time.     The  cause  has  much  to  influence  a  radical  cure- 


yO  PRACTICE    OF    MI-UICINK. 

Treatment.  For  the  paroxysm,  hypodermic  injections  of  mor- 
phtncE  sulphas,  gr.  j^-^  (0.02-0.03  Gm.),  or  the  stomachic  adminis- 
tration of  the  "  compound  of  anodynes,"  the  so-called  chlorodyne,  in 
doses  of  n\,x-xxx  (0.6-2  Cc.)  p.  r.  n.  The  relief  afforded  by  opium  in 
some  form  is  so  decided  that  it  is  apt  to  lead  to  the  opium  habit  when 
the  attacks  are  frequent.  A  mild  attack  may  be  relieved  by  antipyrin, 
gr.  X  (0.65  Gm.).  A  hot  water  bag  over  the  stomach  is  of  great 
value.     In  recurring  attacks  Van  Valzah  recommends  : 

R.     Codein., ^-  %  -O'^      Gm. 

Ext.  cannab.  indioc, S""-  I's  •'^^      ^m. 

Atropina;  sulphas, gr.  ^^^  .00032  Gm. 

Aconilinae gr.  ^^^  .00016  Gm.    M. 

Ft.  capsul. 

SiG. — One  every  four  or  six  hours. 

Galvanization  often  gives  prompt  relief. 

In  the  interval,  regulated  diet  and  one  or  more  of  the  following 
remedies :  argenti  nitras,  quinincB  sulphas,  arsenicutn,  bismuth  sali- 
cylas,ferrum,  liquor  iodiicomp.,  or  small  doses  oi  potassii  iodiduvi. 


ATONIC  DYSPEPSIA. 

Synonyms.     Dyspepsia  ;  indigestion  ;  heartburn  ;  pyrosis. 

Definition.  A  functional  derangement  of  the  stomach,  with  either 
deficient  secretion  in  the  quantity  ox  ^z/a/zVyof  the  gastric  juice;  char- 
acterized by  disorders  of  the  functions  of  digestion  and  assimilation 
and  the  presence  of  sympathetic  nervous  symptoms. 

Causes.  Imperfect  mastication  ;  bolting  of  food  ;  eating  large 
quantities  of  food ;  same  diet  long  continued;  depressed  nervous 
system,  from  worry  and  fatigue  ;  sedentary  habits  or  occupations.  It 
is  often  inherited. 

Symptoms.  Perverted  appetite,  capricious  or  lost ;  difficult  di- 
gestion, a  feeling  of  weight  or  fullness  in  the  epigastrium  ;  acidity 
from  the  decomposition  of  albuminoids  ;  heartburn, fiatulc7icy,  regur- 
gitation, or  vo?niting  of  portions  of  partly  digested  food  or  acrid 
fluid — water- brash  or  pyrosis.  Pain  or  soreness  at  the  "pit  of  stom- 
ach "  during  digestion.  Tongue  either  clean  or  broad,  flabby,  and 
pale,  showing  marks  of  the  teeth.  .fftfWif/.y  constipated  ;  «r/«<f  gener- 
ally scanty  and  high-colored,  with  excess  pf  urates  or  oxalates,  or,  in 


DISEASES   OF  THE  STOMACH.  97 

persons  of  nervous  type,  it  is  pale,  of  low  specific  gravity,  and  con- 
tains phosphates.  Drowsiness  after  meals,  with  wakefulness  at  night, 
defective  memory,  headache,  and  absent  mental  vigor,  vi\'Ca. flashes  of 
heat,  followed  by  more  or  less  perspiration.  Palpitation  of  the  heart 
with  irregularity  in  rhythm. 

Varieties  of  Dyspepsia. — I.  Nervous  dyspepsia,  atonic  form,  seen  in 
active  business  or  busy  professional  men,  especially  those  of  thin, 
spare  build,  of  nervous  temperament,  who  eat  meals  rapidly  and 
hurry  off  to  their  business.  These  cases  present  all  the  marked 
nervous  phenomena,  such  as  drowsiness  after  meals,  and  feeling 
worse  after  a  nap  ;  inability  for  mental  exertion  after  meals,  defective 
memory,  headaches,  at  times  vertigo  and  sleepless  nights.  II.  Flat- 
ulent dyspepsia,  seen  in  hysterical  individuals,  and  showing  immense 
development  of  gas  throughout  the  abdomen,  associated  with  vertigo 
and  mental  worry  or  hypochondria.  III.  Acid  dyspepsia,  water- 
brash.  Seen  when  the  diet  is  coarse.  Acidity  of  the  gastro-intes- 
tinal  canal  and  of  the  urine.  IV.  Irritative  dyspepsia.  Vomiting  a 
prominent  symptom.  In  these  cases  the  tongue  is  small,  red,  and 
pointed. 

Prognosis.  With  careful  living,  dyspepsia,  functional  in  charac- 
ter, is  curable.     It  has  been  aptly  termed  "remorse  of  the  stomach." 

Treatment.  The  most  important  indication  is  to  regulate  the 
diet.  Forbid  saccharine,  starchy,  or  fatty  articles  of  food.  Eat  small 
amounts  at  a  time,  underdone  meats  or  "  Salisbury  steaks,"  eggs, 
fish,  oysters,  and  green  vegetables,  with  stale  or  brown  bread.  Per- 
fect insalivation  and  mastication.  Rest  after  eaiijtg,  from  a  half  to 
an  hour.  Allow  but  small  quantities  of  liquids  with  the  meals. 
In  the  vast  majority  of  C2lSQ5,  forbid  the  use  of  stijnulants  with  the 
meals. 

Aid  digestion  with  pepsinum,  with  or  without  acidum  hydrochlori- 
cum  dilutum. 

R .     Pepsini  purae, 3  j  4.  Gm. 

Acid,  hydrochlorici  dil.,    .    .    .    -  f^iv  15.  Cc. 

Glycerini, f.^i*^  ^5-  *-''^' 

Aq.  lauro-cerasi, fgij  60.  Cc.  M. 

SiG. — One  teaspoonful  with  meals,  diluted. 

Excellent  results  have  followed  the  use  of  a  new  remedy  known  as 
taka- diastase,  gr.  ij-iv  (0.13-0.26  Gm.)  at  meal  time. 
7 


98  PRACTICE   OF    MEDICINE. 

Stitnulaie  stomachic  peristalsis  with  nux  vomica, gentian,  o<  cin- 
chona. 

For  acidity,  alkalies  at  time  of  acidity,  the  very  best  being  sodii 
bicarbonas. 

Yox flatulency,  carbo  animalis purificatus,  gr.  x-xx  (0.65-1.3  Gni.),  or 
one  or  more  of  the  carminatives,  with  tinctura  nucis  vomica  before 
meals. 

Yox  pyrosis,  bismuth,  gr.  xx  (1.3  Gm.),  3inA  pulvis  aromaticus,  gr.  v 
(0.32  Cm.). 

For  vomiting,  sodii  or  strontii  bromidum  in  small  doses,  or  acidum 
carbolicum,  gr.  ^-X  (0.011-0.016  Gm.),  three  or  four  times  daily,  or 
chloral  hydrate,  gr.  x-xv  (0.65-1  Gm.),  in  a  demulcent  by  the  mouth 
or  rectum,  repeated  p.  r.  n. 

For  constipation,  resina  podophyllum  at  bedtime,  or  Hunyadi  Janos 
water  before  breakfast,  hot,  or — 

R.     Ext.  cascarae  sagradae  fld. ,    .    .    •  f^j  30.  Cc. 

Tinct.  nucis  vomicse,      f.^ss  15.  Cc. 

Syr.   zingib. , f.^ss  15.  Cc. 

Inf.  sarsaparilire,     .    .    .    q.  s.  ad  f^iij  ad  90.  Cc.  M. 

SiG. — Teaspoonful  three  times  daily,  diluted. 

For  anamia,  viassa  ferri  carbonatis  ox  ferri  lactas. 

Irrigation  of  the  stomach  or  lavage  often  gives  remarkable  relief. 
The  drinking  of  hot  water  one-half  to  one  pint  an  hour  before  meals 
is  of  benefit. 

A  homely  but  efficient  combination  for  atonic  dyspepsia  associated 
with  scanty,  acid  urine  and  constipation,  is — 

B  .     Sodii  bicarbonatis 3  ij  8.  Gm. 

Tinct.  nucis  vomicae, f.^'^  ^5-  Cc. 

Tinct.  capsici, fzj  4.  Cc. 

Tinct.  rhei,      f.S'ss  45.  Cc. 

Inf.  gentian,  comp.,    ....     adf^vj  ad  180.  Cc.  M. 

SlG. — Half  tablespoonful  after  meals,  in  water. 

I  have  seen  excellent  results  in  many  cases  of  dyspepsia  and  indi- 
gestion from  the  following  combination  : 

R.     Papoid  (puras) gr.  xxx  2.     Gm. 

Sodii  bicarb. , gr.  Ix  4.     Gm. 

Pulv.  zingib.  jam., gr.  v  .3  Gm.  M. 

Et  capsul.  or  pil.  No.  xx. 

SlG. — One  at  meal-time  and  bedtime. 


DISEASES   OF  THE   INTESTINAL  CANAL.  99 


DISEASES   OF  THE    INTESTINAL   CANAL. 


INTESTINAL   INDIGESTION. 

Synonym.     Intestinal  dyspepsia. 

Definition.  A  derangement  in  the  functions  of  intestinal  diges- 
tion, resulting  in  the  more  or  less  complete  decomposition  of  the 
chytne,  caused  by  defects  in  the  pancreatic,  biliary,  or  intestinal 
secretions  or  from  deficient  peristalsis,  one  or  more  of  these,  singly 
or  combined  ;  characterized  by  abdominal  pain  and  distention  and 
tympanites  developing  some  hours  after  meals,  and  nervous  perturba- 
tion, anaemia,  and  emaciation. 

Causes.  Imperfect  diet ;  over-eating  ;  irregularity  in  eating  ;  de- 
ficient exercise;  worry;  immoderate  use  of  tobacco  or  stimulants; 
diseases  of  the  stomach,  intestinal  tract,  liver,  or  pancreas;  malaria. 
Frequently  inherited. 

Symptoms.  Intestinal  indigestion  may  be  either  acute  or  chronic, 
the  latter  the  more  common. 

Aciite  variety,  the  result  of  an  irritant  in  the  duodenum,  rapidly 
developed  pain,  fiaiulency ,  borborygmi,  slight  feverishness,  coated 
tongue,  loss  of  appetite,  headache,  pains  in  the  limbs,  usually  termi- 
nating in  a  mild  attack  of  diarrhcea. 

If  the  attack  develops  rapidly,  the  sudden  formation  of  gases 
causes  a  paroxysm  of  colic. 

Severe  attacks  are  associated  with  disordered  hepatic  function, 
light-colored  stools,  slight  jaundice,  and  high  colored  urine.  In  these 
severe  attacks  the  symptoms  develop  gradually  with  general  malaise, 
or  abruptly  with  chill  or  chilliness  followed  by  fever  ioo°-io2°,  in- 
creased pulse,  headache  with  or  without  vomiting,  the  tongue  white 
coated,  soon  becoming  red,  dry,  and  glazed,  with  abdominal  pains 
increased  by  pressure,  tympanites  and  flatulency  succeeded  by  diar- 
rhcea,  the  stools  averaging  from  two  to  a  dozen,  at  first  soft  and  nor- 
mal with  fecal  odor  and  color,  later  becoming  watery  and  frothy  with 
a  most  persistent,  offensive  odor,  containing  mucus  and  particles  of 
undigested  food.     The  reaction  of  stools  is  alkaline,  rarely  acid.    The 


100  PRACTICK    OK    MEDICINE. 

microscope  shows  epithelial  cells,  round  cells,  occasionally  blood- 
cells,  bacteria,  Charcot's  crystals,  crystals  of  oxalate  of  calcium, 
calcium  phosphate,  etc.     Cramps  in  lower  limbs,  often  very  severe. 

Chronic  variety,  resulting  from  a  greater  or  less  decomposition  of 
the  partly  altered  food  from  the  stomach.  Pain,  varying  in  character, 
occurring  from  two  to  four  or  six  hours  after  meals,  with  slight 
tenderness  and  some  fullness  in  the  right  hypochondrium,  epigas- 
trium, or  the  umbilical  region.  Tympanites  and  borborygmi  are 
marked,  the  result  of  gaseous  accumulations  which  have  developed 
from  the  decomposition  of  the  intestinal  contents.  Dyspncea,  the 
result  of  pressure  against  the  diaphragm,  is  of  frequent  occurrence. 
Marked  nervous  phenomena  develop,  the  result  of  the  anaemia  from 
deficient  assimilation  and  from  the  depressing  influence  on  the 
nervous  system  of  the  absorption  of  the  "  gases  of  decomposi- 
tion." 

The  skin  is  harsh  and  dry,  the  bowels  are  sluggish  or  constipated, 
the  urine  is  high  colored,  of  increased  density,  decidedly  acid, 
and,  on  cooling,  deposits  lithates,  uric  acid,  and  oxalate  of  lime 
crystals. 

Functional  derangement  of  the  liver  follows  after  a  time,  adding  to 
the  general  discomfort. 

Anatnia  and  emaciation  result  if  the  attack  be  protracted  from  the 
imperfect  secondary  assimilation. 

Diagnosis.  With  our  present  knowledge  it  is  usually  impossible 
to  designate  forms  of  intestinal  indigestion  due  to  defects  in  the 
quantity  or  quality  of  either  the  pancreatic,  biliary,  or  intestinal 
secretions. 

Acute  intestinal  indigestion  differs  from  gastric  indigestion  in  the 
time  of  development  of  the  various  phenomena,  in  the  latter  the 
symptoms  appearing  almost  immediately  after  meals,  while  in  the 
former  not  appearing  until  two,  four,  or  six  hours  after. 

Chronic  intestinal  indigestion  may  mislead  the  physician  if  the 
various  nervous  phenomena  are  of  a  marked  character,  and  a  careful 
history  of  the  case  is  not  developed. 

Prognosis.  Favorafble  if  proper  and  early  treatment  be  inaugu- 
rated, unless  the  result  of  an  organic  lesion. 

Treatment.  Acute  variety,  the  result  of  undigested  food,  is  best 
treated  by  opium  in  some  form,  to  relieve  the  acute  suffering,  warmth 
to  the  abdomen,  and  a  prompt  cathartic  to  cause  its  rapid  expulsion. 


I^. 

Cc. 

!=;• 

Cc. 

IS- 

Cc. 

ad  90. 

Cc. 

DISEASES   OF  THE   INTESTINAL   CANAL.  101 

or  six  or  eight  calomel  powders  two  or  three  hours  apart,  followed 
the  next  morning  by  a  saline — 

R.     Hydrarg.  chlor.  mit., S^-  H  .02  Gm. 

Sodii  bicarb., gr.  ij  .13  Gm. 

Pulv.  ipecac, gr-  ^  -Oi  Gm. 

Sacch.  lact. , g^-  iij  -2    Gm.  M. 

Ft.  charta. 

After  which  stimulate  the  gastro-intestinal  canal  with : 

R  .      Tinct.  nucis  vomicae, f  3  i^ 

Acid,  hydrochlorici  dil.,     .    .    c    ■  f^iv 

Tinct.  card,  comp., f^i^ 

Ess.  pepsin., q.  s.  adf5iij  ad  90.  Cc.  M. 

SiG. — Teaspoonful  every  three  hours,  diluted. 

For  the  more  severe  variety  of  intestinal  indigestion  (or  catarrh), 
wash  out  large  bowel  with — 

R.     Magnesii  sulph., ^]  30.  Gm. 

Glycerini, f 5j  30.  Cc. 

Aqu«  bul. ,       f  d  ^v  ^2°-  ^^*  ^• 

Slowly  injected  into  bowel  from  a  fountain  syringe. 

Internally  either  of  the  following  excellent  combinations : 

R.     Naphtalini,      gr.  xxx  2.       Gm. 

Bismuth,  salicyl., gr.  Ixxx  6.       Gm. 

Acid,  carbolici, gr.  iv  .26  Gm. 

Glycerini, f_^j  30.      Cc. 

Aq.  chloroformi,     .......  fjiij  90.       Cc.  M. 

SiG. — Two  teaspoonfuls  every  two  or  three  hours,  diluted. 

Or— 

R.  Sodii  phosphat., 
Acid,  phosph.  dil., 
Syr.  limonis,  .  .  . 
Aq.  chloroformi,  . 
Aq.  menth.  pip.,  . 
SiG. — One  tablespoonful  after  meals,  well  diluted. 


30.  Gm. 
15.  Cc. 
30.  Cc. 
90.  Cc. 
100.  Cc.  M. 


In  all  cases  carefully  designate  the  charactel  and  amount  of  food, 
and  times  of  administration. 

Chronic  cases.  Of  the  first  importance  is  the  diet,  which  should  be 
restricted  in  amount  and  confined  almost  entirely  to  articles  which 
are  readily  digested  in  the  stomach,  such  as  beef,  eggs^  and  milk' 


102  PRACTICE    OF    MEDICINE. 

Aid  intestinal  digestion  by  the  administration  of — 

K-     Papoid, gr.  j-ij  .065-.  13  (Jm. 

Naphtalini,       gr.  j  .065  Gm. 

Ext.  nucis  vomicae, %^-  Vi  -^^z  Gm.     M. 

Ft.  pil. 

One  such  to  be  taken  every  four  or  six  hours. 

Or  liquor  pancreaticus,  f3j-iv  (4-15  Cc);  or  extractum  pancreatis, 
gr.  ij-v  (0.13-0.3  Gm.),  with  sodii  bicarbonatis,  gr.  v-x  (0.3-0.6  Gm.), 
two  or  three  hours  after  meals ;  or  fcl  bovis  purificatum,  gr.  j-iij 
(0.065-0.2  Gm.),  after  meals. 

Excellent  results  from  the  use  of  the  following  pill : 

B  .     Sodii  arseniat., g*"- 2V  .003  Gm. 

Stryclininn:  sulph., gr.  -^^  .002  Gm. 

Pepsi  nixi  purrc, g*"-  ij  •''3    Gm. 

After  each  meal. 

For  constipation,  bitter  waters,  such  as  Bedford,  Friedrichshall, 
Pullna,  or  Hunyadi  Janes,  or  resina  podopJiylliim,  or  extractum 
cascarcE  sagrada  Jiuidum,  at  bed-time. 


INTESTINAL  COLIC. 

Synonyms.     Enteralgia  ;  tormina  ;  gripes. 

Definition.  A  spasmodic  contraction  of  the  muscular  layer  of 
the  intestinal  tube;  characterized  by  acute  paroxysmal  pain  near  the 
umbilicus,  relieved  by  pressure,  and  associated  with  feeble  cardiac 
action. 

Causes.  Constipation;  presence  of  indigestible  food  ;  collections 
of  flatus;  an  abnormal  amount  of  bile  discharged  into  the  intestines; 
lead  poisoning  ;  syphilis;  chronic  malaria  ;  rheumatism;  hysteria. 

Symptoms.  Ronbcrg  thus  describes  a  paroxysm  :  "  There  are 
attacks  of /<iz>i,  spreading  from  the  navel  over  the  abdomen,  alter- 
nating with  intervals  of  ease.  The  pain  is  tearing,  cutting,  pressifig, 
most  frequently  twisting,  pinching,  accompanied  by  peculiar  bear- 
ing-down pains.  The  patient  is  restless,  and  seeks  relief  xw  changing 
his  position  and  in  compressing  the  abdomen;  his  surface  maybe 
cold  and  his  features  pinched.  The  pulse  is  small  and  hard.  The 
abdomen  is  tense,  whether  puffed  up  or  drawn  inward.     There  are 


DISEASES   OF  THE   INTESTINAL  CANAL.  103 

often  nausea  and  vomiting,  and  desire  for  stool.  There  is  usually 
constipation,  but  sometimes  the  bowels  are  regular  or  even  too  loose. 
Duration  from  a  few  minutes  to  several  hours,  relaxing  at  intervals. 
The  attack  ceases  suddenly,  with  a  feeling  of  the  greatest  relief, 
although  some  soreness  remains  for  a  few  days." 

Lead  colic  is  always  preceded  by  symptoms  of  lead  poisoning,  to 
wit:  slate-colored  skin,  dark  gums  showing  a  blue  line,  heavy  breath, 
with  sweetish  metallic  taste,  obstinate  constipation,  impaired  appetite, 
slow  pulse,  and  contracted  abdominal  walls. 

Diagfnosis.  Gastralgia  differs  from  colic,  in  the  pain  being  in  the 
epigastric  region  and  associated  with  disorders  of  digestion. 

In  hepatic  colic,  or  the  passage  of  gallstones,  the  pain  is  in  the 
hepatic  region,  attended  with  soreness  over  the  gall  bladder,  and 
retching  and  vomiting,  followed  by  jaundice  and  the  presence  of  bile 
in  the  urine. 

In  nephritic  colic,  the  pain  follows  the  course  of  one  or  both  ureters, 
shooting  to  loins  and  thigh,  with  retraction  of  the  testicle  of  the  affected 
side,  strangury,  and  bloody  urine. 

In  uterine  colic,  the  pain  is  in  the  pelvis,  and  associated  with  men- 
strual disorders,  in  fact,  a  dysmenorrhoea. 

In  ovarian  colic  or  neuralgia,  pain  or  pressure  over  the  ovaries, 
with  hysterical  phenomena. 

Infla7nmatory  disorders  of  the  abdomen  differ  from  colic  by  the 
presence  of  fever  and  tenderness  on  pressure. 

Prognosis.  Most  favorable.  Death  is  the  rarest  termination 
possible. 

Treatment.  Relief  of  pain  is  the  first  indication,  and  is  best  ac- 
complished by  a  hypodermic  injection  of  morphiticR  sulphas,  gr.  yi-yi 
(0.011-0.022  Gm.),  which  has  the  additional  advantage  of  relaxing 
the  spasm,  thereby  favoring  the  action  of  purgatives,  which  should 
soon  follow.  One  of  the  best  in  colic,  no  matter  from  what  cause,  is 
massce  hydrargyrum,  gr.  v-x  (0.3-0.6  Gm.),  or  hydrargyri  chloridum 
mite,  gr.  ^  (0.03  Gm.)  every  half  hour  until  four  or  five  grains  are 
taken,  followed  by  a  mild  saline  cathartic. 

After  the  relief  of  the  pain  and  free  action  of  the  bowels,  the  cause 
of  the  attack  should  be  ascertained  and  corrected,  to  prevent  future 
suffering. 

For  lead  colic,  morphines  sulphas  for  the  pain ;  oleum  ricini  or 
magnesii  sulphas,  3j  (4  Gm.)  every  hour,  for  the  constipation,  and 


1Q4  PRACTICE    OF    MEDICINE. 

po/iissii  iodidum,  gr.  v-x  (0.3-0.6  Gm.)  after  meals,  or  syrupus 
acidi  Iiydf  iodic i,io]-^v  (4-15  Cc.)  after  meals,  diluted,  to  eliminate 
the  metal  from  the  system.  Excellent  results  often  follow  a  fiee  or 
several  small  venesections  in  lead  poisoning. 

Gratifying  results  in  attacks  of  lead  colic  have  been  reported  from 
tumblerful  doses  of  oUnm  oliva,  repeated  until  some  six  ounces 
(180  Cc.)  have  been  used.  It  is  said  to  be  curative  in  lead  poisoning, 
in  daily  doses  of  two  ounces,  continued  for  some  time. 


CONSTIPATION. 

Synonyms.     Intestinal  torpor;  costiveness. 

Definition.  A  functional  inactivity  of  the  intestinal  canal,  either 
due  to  atony  of  the  muscular  coat,  causing  lessened  peristalsis,  or  to 
a  deficiency  of  intestinal  and  biliary  secretion  ;  characterized  by  a 
change  in  the  character,  frequency,  and  quantity  of  the  stools. 

Causes.  Dyspepsia;  character  of  the  food;  habits  of  the  patient, 
as  sedentary  habits  and  neglecting  calls  of  nature ;  diseases  of  the 
stomach  and  liver;  malaria;  lead  poisoning ;  syphilis. 

Symptoms.  In  the  normal  condition  the  majority  of  persons 
have  one  stool  each  day,  although  it  is  not  to  be  considered  abnormal 
if  more  or  less  than  that  number  occur. 

The  bowels  are  moved  every  three  ox  four  days,  with  great  straining 
and  distress,  the/atv  oktn  flushed,  the  cerebral  vessels  full ;  leaving 
an  uneasy  sensation  in  the  rectum. 

Or  in  other  cases  the  bowels  may  be  relieved  once  a  day,  but  the 
stool  is  small  and  hard,  causing  great  distress,  and  tenesmus,  or  teaz- 
ing. 

Another  group  of  cases  \\2iMt  frequent  stools  during  the  day,  small 
and  non-formed,  due  to  retained  hardened  feces  acting  as  an  irritant 
upon  the  rectum. 

The  change  in  the  character  of  the  stools  is  soon  followed  by 
symptoms  of  dyspepsia,  headache,  mental  torpor,  vertigo,  palpitation 
on  exertion,  and  in  many  cases  with  great  distention  of  the  abdomen. 

Prognosis.     Death  never  results  from  functional  constipation. 

Treatment.  The  successful  treatment  depends  upon  the  removal 
of  the  cause  and  the  hearty  co-operation  of  the  patient. 

First,  the  patient  must  have  a  regular  hour  each  day  for  going  to 


DISEASES   OF  THE   INTESTINAL   CANAL.  105 

stool,  and  must  remain  a  sufficietit  time  to  permit  a  thorough  evacua- 
tion of  the  bowels,  assisting,  until  habit  of  daily  stools  is  formed,  by 
a  warm  water  injection. 

Second,  the  diet  must  be  carefully  regulated,  as  concentrated  foods 
increase  the  costive  habit,  so  that  those  predisposed  should  eat  bulky 
foods,  much  vegetables  and  fruits. 

Third,  purgative  mineral  waters  or  cathartic  medicines  are  to  be 
used  with  catition,  their  reckless  administration  often  causing  more 
injury  than  benefit. 

Fourth,  either  of  the  following  formulse,  aided  by  the  enforcement 
of  the  above  rules,  will  give  good  results  : 

R.     Ext.  nucis  vomicse, ^- %  .016  Gm. 

Ext.  belladonnae  alco., gr-  X  •°''^  ^™* 

Ext.  aloes  aqua., gr.  ss  .032  Gm. 

Pulv.  rhei, gr.  j  .065  Gm. 

Olei  cajuputi, rr\^  j  .06    Cc.  M. 

In  pill,  at  bedtime  ;   and  after  a  week,  every  second  or  third  night. 

B .     Resina  podophyl., 
Ext.  physostig., 
Ext.  belladonnae  alco. , 
Aloini,      aa  gr.  X  aa     .016  Gm. 

Id  pill,  every  night,  or  second  or  third  night. 

R.     Ext.  cascarse  sagradse  fld.,    .    .    .    TTI^xx  1.3  Cc. 

Glycerini, tT\^xx  1.3  Cc. 

Syr.  sarsaparillae, Tt\,xx  1. 3  Cc. 

Hour  after  meals,  or  once  a  day,  as  indicated. 

All  cathartics  and  purgatives  are  improved  by  the  addition  of  a 
small  amount  of  sulphur  praecipitatum. 

One  of  the  very  best  purgatives  is  an  early  morning  dose  of  magnesii 
sulphas  (Epsom  salts).  Another  excellent  tonic  purgative  is  aldinum, 
gr.  y%-)i  (0.008-0.016  Gm.),  after  meals. 

Success  often  follows  an  enema  o{ glycerinum,i'Z]-\v  (4-15  Cc),  or 
a  suppository  of  glycerinum. 

Electricity  to  the  abdomen  is  worth  a  trial ;  one  pole  over  abdomen, 
the  other  at  anus,  using  either  galvanism  or  faradism.  Kneading  the 
abdomen  is  frequently  of  benefit. 


106  PRACTICE    OF   MEDICINE. 


DIARRHCEA. 


Synonyms.     Enterorrhoea  ;  alvine  flux  ;  purging. 

Definition.  Frequent  loose  alvine  evacuations,  without  tenes- 
mus; due  to  functional  or  organic  derangement  of  the  small  intes 
tines,  produced  by  causes  acting  either  locally  or  constitutionally. 

Causes.  Those  acting  locally,  such  as  indigestion,  indigestible 
food,  impure  food  and  water,  irritating  matters  or  secretions  poured 
into  the  bowels,  or  entozoa,  cause  the  flux  by  a  direct  irritation  of  the 
mucous  surface. 

Attacks  of  diarrhoea  due  to  constitutional  derangement  may  be 
secondary  to  such  diseases  as  tuberculosis,  pycemia,  albuminuria, 
typhoid  fever,  or  disturbances  of  the  functions  of  other  organs,  giving 
rise  to  vicarious  fluxes. 

Atmospheric  changes,  as  well  as  a  sudden  mental  shock,  will  often 
produce  an  attack  of  diarrhoea  in  those  predisposed. 

Forms.     Acute  and  chronic. 

Symptoms.  Acute  diarrhoea  presents  itself  in  several  varieties, 
the  result  of  the  particular  cause. 

Feculetit  diarrJiCEa.  A  few  hours  after  meals  the  patient  feels 
colicky  pains  and  flatulency,  with  a  desire  for  stool.  There  is  often 
nausea,  coated  tongue,  but  seldom  vomiting.  The  pain  is  generally 
relieved  by  the  purging  which  ensues.  The  stools  have  3.  feculent 
character,  are  of  brown  fluid,  containing  faeces,  often  ofiensive,  the 
color  becoming  lighter  after  four  or  five  evacuations.  Constitutional 
symptoms  are  wanting. 

This  form  is  the  result  of  overeating,  eating  too  rapidly,  or  indi- 
gestion of  different  forms,  or  worms  in  the  intestinal  canal,  and 
patients  generally  recover  in  a  day  or  two. 

Lientcric  diarrhoea.  In  this  form  there  is,  with  the  frequency  of 
evacuations,  a  ivant  of  assimilation  o{food,  which  passes  through  the 
intestines  more  or  less  unaltered.  The  stools  are  frequent,  mucous 
or  serous,  more  or  less  covered  with  bile,  mixed  w'xih.  undigested  food. 
In  this  form  the  patients  emaciate  rapidly,  owing  to  the  deficient 
assimilation,  the  digested  portions  of  the  food  being  hurried  on  by  the 
increased  peristalsis  of  the  irritated  bowel.  It  is  usually  subacute  in 
its  course. 

Bilious  diarrhcea.     The  stools  arc  frequent,  green  or  yellow,  with 


DISEASES   OF  THE   INTESTINAL  CANAL.  107 

scalding  sensations  at  the  anus  and  griping  pains  in  the  abdomen. 
Excessive  biliary  secretion  is  the  irritating  cause. 

Any  of  the  above  forms  may  pass  into  chronic  diarrhoea  by  exciting 
permanent  diseases  of  the  intestines.  Diarrhoea  due  to  constitutional 
causes  will  be  mentioned  when  speaking  of  those  conditions. 

Chronic  diarrhoea  results  from  repeated  attacks  of  the  acute  form, 
or  is  the  result  of  some  cachexia.  The  syiftiptoms,  so  far  as  the  stools 
are  concerned,  are  much  the  same  as  in  the  acute  disease,  except 
they  are  paler,  whence  it  has  been  termed  white  flux  ;  in  addition, 
dyspeptic  symptoms,  aphthous  condition  of  the  mouth  and  tongue, 
flatulency,  colic,  emaciation,  and  aficEniia.  The  appetite  is  at  times 
capricious,  again  impaired.  Exacerbations  result  from  indiscretions 
in  diet  and  from  the  sudden  onset  of  damp  weather. 

Prognosis.  Favorable  va  feculent  and  bilious  forms;  unfavorable 
in  lienteric  and  chronic  forms  when  emaciation  begins.  Diarrhoea 
occurring  as  a  symptom,  the  prognosis  is  controlled  by  the  original 
disease. 

Treatment.  Acute  diarrhoea.  If  the  tongue  is  heavily  coated, 
the  breath  fetid,  and  the  stools  not  excessive  in  number,  it  is  well  to 
clear  the  intestinal  canal  with  a  laxative  such  as  oleum  ricini  or  a 
saline.    For  children  between  one  and  two  years  of  age : 

R.     Pulv.  ipecac, gr.  ss  .032  Gm. 

Pulv.  rhei,       gr.  }i-]A,  .016-.022  Gm. 

Sodii  bicarb. ,      gr.  ss-ij  .032-.  13    Gm.  M. 

Every  four  hours  until  the  character  of  the  stools  changes. 

As  a  rule,  however,  the  stools  have  become  so  frequent  when  ad- 
vice is  sought  that  the  time  for  laxatives  has  passed,  and  some  one  of 
the  following  combinations  is  indicated : 

R.     Salol, gr.  xx-xxx  1-3-2.  Gm. 

Bismuth  subnit., gj  4.  Gm. 

Sacch.  lac, 3J  4.  Gm.  M. 

Ft.  chart.  No.  x. 

SiG. — One  every  two  or  three  hours,  reducing  the  dose  for  children 

Or— 

B .     Bismuthi  salicylat. , gr.  xxx  2.        Gm. 

Morphine  sulph., gr.  j  .065  Gm.  M. 

Ft.  chart.  No.  vj. 

SiG. — One  every  three  hours. 


108  PRACTICE    OF    MEDICINE. 

Oi  the  following  modification  of  "  Squibb's  diarrhoea  mixture": 

R.     Tinct.  opii  deodorat., fS'^  ^5-  Cc. 

Tinct.  camphonv, f  .^ '^  ^5-  Cc. 

Tinct.  capsici, f^ij  8.  Cc. 

Chloroform!  punv, f ::;  iss  6.  Cc. 

Spts.  vini  gallici, f  5j  30.  Cc. 

Villi  pepsini, ad  f^iij  ad     90.   Cc.  M. 

SiG. — One  teaspoonful,  p.  r.  n. 

Or  the  following,  which  I  have  always  found  successful : 

R.     Tinct.  opii  deodorat., fo'^  IS- Co. 

Spts.  chloroformi, f  .^  ij  8.  Cc. 

Acid,  sulphuric,  dil., f^^j  30.  Cc. 

Vini  pei>sini, q.  s.  adf5iij  ad       90.  Cc.  M. 

SiG. — One  teaspoonful  in  water  after  each  stool. 

For  the  bilious  form  : 

R.     Hydrargyri  chlor.  mitis,    ....    gr.  ^  .008  Gm. 

Sodii  bicarb., gr.  ij  .13    Gm. 

Pulv.  opii, gr-  /4  -0x6  Gm.        M. 

In  powder,  every  two  or  three  hours,  until  eight  ix)wders  are  used,  followed 
by  large  doses  of  bismuthum  and  pepsinmn. 

In  all  acute  forms  restricted  and  regiilated  dieta.re  imperative, ^;/r<» 
milk  with  liquor  calcis  being  the  most  suitable. 

In  adults,  an  opium  suppository  often  checks  a  flux  that  is  uninflu. 
enced  by  opium  internally. 

In  lienieric  or  dyspeptic  diarrhoea  a  carefully  regulated  diet  and 
either  of  the  following  combinations  : 

R.     Pepsini  glycerit., f^j  30.     Cc. 

Liq.  potassii  arsenit., Tr\,xx  1.3  Cc. 

Tinct.  opii  deodorat., fzij  8.     Cc. 

Aq.  chloroformi,  ...       q.  s.  ad  f5iij  ad     90.     Cc. 
SiG. — One  teaspoonful  at  meal-time. 

Or— 

R.     Papoid, gr.  XX  1. 3  Gm. 

Bismuth,  subnit. , 3J  4.     Gm.  M. 

Ft.  chart.    No.  x. 

SiG. — One  at  meal-time. 

Chronic  diarrhoea.  Bismuth,  gr.  xxx-xl  (2-2.6  Gm.),  in  milk, 
every  four  hours;  Hope's  camphor  mixture,  fjj  (30  Cc),  every  four 


DISEASES   OF  THE   INTESTINAL  CANAL.  109 

hours;  or  cupri  sulphas,  gr.  j\ (0.005  Gm.),  ext.  opii,  gr.  ^^  (0.005 
Gm.),  every  four  hours  ;  or  argenti  nitras,  gr.  yk,  (o.oi  Gm.),  ext.  opii, 
gr.  \  (o.oii  Gm.),  every  five  hours;  may  all  be  used  with  more  or 
less  success  ;  when  dry  tongue  and  great  flatulency  use : 

R.     01.  terebinthin^, fzj  4.  Cc. 

01.  amygdal.  express.,  .....  fgss  15-  Cc. 

Tinct.  opii, f^ij  8.  Cc. 

Mucil.  acacise, f  ^iv  15.  Cc. 

Aq.  lauro-cerasi, fsss  15.  Cc.  M. 

SiG. — f^j  every  three  or  four  hours,  diluted. 

The  diet  should  be  nutritious  in  character,  and  moderate  stimulants 
are  indicated.  Activity  of  the  skin  and  kidneys  should  be  encour- 
aged. 

All  varieties  of  intestinal  catarrh  or  diarrhoea  are  benefited  by  a 
few  days'  rest  in  bed  and  daily  hot  baths. 


CATARRHAL  ENTERITIS. 

Synonyms.  Intestinal  catarrh  ;  acute  diarrhoea ;  inflammation 
of  the  bowels. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  small  intestines  ;  characterized  by  fever,  pain,  tenderness,  and 
looseness  of  the  bowels.  When  the  catarrh  is  limited  to  the  duode- 
num it  is  termed  duodenitis,  and  there  is  some  jaundice. 

Pathological  Anatomy.  There  first  ensues  hypercemia  of  the 
mucous  membrane  and  intestinal  glands,  manifested  by  redness, 
swelling,  and  oedema;  this  is  followed  by  increased  secretion,  and  an 
overgrowth  and  desquamation  of  the  epithelium,  together  with  a  copi- 
ous generation  of  young  cells.  As  a  result  of  the  hypersemia,  rupture 
of  the  capillaries  and  extravasation  of  blood  often  occur. 

The  swollen  glands  show  a  strong  tendency  to  ulcerate.  This 
catarrhal  process  may  involve  the  entire  tube  or  be  limited  to  portions 
of  it.  If  the  catarrhal  changes  extend  to  the  ileum,  the  solitary  and 
Peyerian  glands  show  swellings  that  might  be  mistaken  for  the  changes 
of  typhoid  fever. 

Causes.  A  specific  virus  seems  probable  in  some  cases.  Per- 
haps a  ptomaine  poisoning.    Improper  and  indigestible  food ;  summer 


no  PRACTICK    OF    MKDICINE. 

temperature  and  exposure  to  cold  and  wet,  while  perspiring.  Swal- 
lowing fish-bones,  cherry-stones,  unmasticated  kernels  of  nuts,  etc. 

Symptoms.  Begins  with  latii^uor,  followed  by  chilliness  and 
fcvcr,  the  temperature  ranging  at  102°-I03°;  this  is  followed  hy  pain, 
colicky  and  paroxysmal  in  character,  situated  above  the  umbilicus, 
localized  tenderness,  and  loose  evacuations.  Nausea  and  vomiting 
often  occur.  The  bowels  are  at  first  constipated,  followed  by  per- 
sistent diarrhoea;  the  stools  contain  but  little  fecal  matter,  are  yellow 
ox  greenish-yellow  in  color,  mixed  with  undigested  food ;  if  the  stools 
are  numerous,  they  become  whitish  and  watery,  the  so-called  "rice- 
water"  discharges.  No  blood  in  the  stools.  The  appetite  is  im- 
paired, and  this,  with  the  want  of  assimilation  and  great  waste,  soon 
produce  extreme  weakness  and  emaciation,  which  is  always  more 
marked  in  children.  I  have  frequently  noted  a  peculiar  abdominal 
eruption  in  severe  cases  of  intestinal  catarrh,  occurring  as  isolated 
dark-red  spots,  larger  than  those  of  typhoid  fever,  lasting,  each, 
twenty-four  hours,  disappearing  on  pressure  and  with  the  decline 
of  fever. 

Duration.  In  mild  cases,  four  or  five  days;  severe  cases  con- 
tinue, more  or  less  marked,  for  a  week  or  two. 

Diagnosis.  From  colic,  by  the  absence  of  tenderness  and  fever, 
and  presence  of  constipation  and  its  paroxysmal  character. 

From  typhoid  fever,  by  the  absence  of  prodromes,  characteristic 
step-like  temperature  record,  characteristic  eruption,  enlarged  spleen, 
and  peculiar  character  of  the  stools. 

For  points  of  distinction  from  dysentery  or  peritonitis,  see  those 
affections. 

Prognosis.  Favorable,  if  early  and  proper  treatment  is  em- 
ployed. 

Treatment.  Rest  the  bowels  by  a  restricted  diet,  such  as  milk 
and  lime-water,  or  weak  mutton  or  chicken  soups,  with  well-boiled 
rice  added. 

Keep  the  patient  quiet  in  bed,  a  difficult  matter  in  the  case  of 
children. 

For  adults,  opium  is  the  remedy,  in  doses  to  control  the  symptoms; 
mild  doses  do  well  with — 

R.     Ext.  opii, gr- X~/^       .016-.032  Gm. 

Camphone  pulv., gr.  iij  .2  Gm.         M. 

In  pill,  every  three  hours. 


DISEASES   OF   THE   INTESTINAL  CANAL.  Ill 

Or— 

R.     Tinct.  opii  deodorat.,    .....    TT\,x  .6  Cc- 

Liq.  potassii  citrat., f^ij  S.     Cc.  M, 

Every  hour  until  opium  effect. 

The  strength  and  the  frequency  of  administration  of  either  of  tliese 
formulas  must  be  governed  by  the  severity  of  the  attack. 

Salol,  gr.  j-iij  (0.065-0.2  Gm.),  alone  or  combined  with  bismutki 
:alicylas,  gr.  x-xv  {0.6-1  Gm.),  every  few  hours,  is  often  of  value  in 
intestinal  catarrh,  although  my  experience  is  more  fivorable  to 
opium. 

If  vomiting  is  annoying,  all  other  treatment  must  be  discontinued 
until  it  has  been  controlled,  the  following  being  usually  efficient : 

R .     Hydrargyri  chlor.  mite,    ....    gr.  ^  .008  Gm. 

Sodii  bicarbon., gr-  ij  .13    Gm. 

Sacch.  lac, gr.  ij  .13    Gm.        M. 

Give  every  hour  or  two,  dry,  on  tongue. 

For  children  : 

5c .     Tinct.  opii  deodorat. , Try'  .06  Cc. 

Bismuth,  subnit., gr-  v  .32  Cc. 

Mist,  cretse, fgj  4.       Cc.  M. 

Every  two  hours,  for  a  child  of  one  year. 

If  the  disease  shows  the  least  tendency  to  linger,  the  flir/rt^  treatment 
should  be  substituted,  one  of  the  best  formulae  being  "  Hope's  Cam- 
phor Mixture."  The  following,  which  I  have  used  with  much  success 
in  the  insane  wards  of  the  Philadelphia  Hospital,  where,  at  times,  we 
see  a  good  deal  of  intestinal  catarrh,  and  which  I  have  named  "  Mis- 
tura  enterica,"  is  generally  satisfactory: 

5t.     Spts.  camphors, f^j  30.  Cc. 

Acid,  sulphurici  dil., f^iss  45.  Cc. 

Tinct.  opii  deodorat., f  5j  30.  Cc. 

Tinct.  capsici, f^ss  15,  Cc 

Spts.  chloroformi, f.^ss  15.  Cc. 

Spts.  vini  gallici,     .    .      q.  s.  adf^vj  ad     180.  Cc.                M. 

SiG. — One  to  two  teaspoonfuls,  well  diluted,  every  three  or  four  hours. 

Locally.  Poultices,  warm  fomentations,  such  as  a  turpentine 
stupe,  or  ung.  belladonna  or  oleum  camphoratce,  are  agreeable. 


112  I'KACTICE    OF    MKUICINE. 


CROUPOUS  ENTERITIS. 

Synonym.     Membranous  enteritis. 

Definition.  A  croupous  inflammation  of  the  mucous  membrane 
of  the  small  intestines;  characterized  by  tenderness,  paroxysmal 
pain,  moderate  fever,  and  the  formation  and  discharge  at  stool  of 
membranous  shreds  or  casts. 

Causes.  A  disease  of  adult  life.  The  female  sex  more  liable 
than  the  male,  and  neuralgic,  nervous,  hysterical,  or  hypochondriacal 
subjects  are  more  subject  to  it  than  are  other  types. 

A  peculiar  state  of  the  nervous  system  seems  necessary  to  its  pro- 
duction.    It  is  not  a  frequent  disease. 

Pathological  Anatomy.  A  subacute  inflammation  of  the  small 
intestine,  during  which  the  mucous  membrane  becomes  covered  with 
a  whitish  or  grayish-white,  firmly  adherent,  membranous  deposit, 
cemented  together  by  a  coagulable  exudation,  and  prolonged  by 
rootlets  from  the  under  surface  into  the  intestinal  follicles. 

Symptoms.  Begins  hy  feverishness,  feeling  of  soreness  and  eiis- 
tetition  of  the  abdomen;  these  are  followed  hy  pains  of  a  colicky 
character,  severe  and  depressing,  felt  around  the  umbilicus,  asso- 
ciated with  tenderness,  continuing  for  half  an  hour,  an  hour,  or  longer, 
and  after  a  longer  or  shorter  interval  occurring  again  ;  these  pheno- 
mena continue  for  a  day  or  two,  when  looseness  of  the  bowels  with 
distressing  pain  and  tenesmus  occur,  the  stools  containing  mucus, 
with  or  without  blood,  and  shreds  of  membrane  or  cylindrical  casts  of 
the  bowel.  Great  relief  follows  the  discharge  of  shreds,  although  a 
feeling  of  rawness  or  soreness  persists  for  a  few  days. 

Preceding  the  local  manifestations  of  the  disease  are  attacks  of 
hysteria,  hypochondriasis,  neuralgia,  nervousness,  or  excitability. 

The  paroxysms  recur  at  intervals  of  a  week  or  two,  or  after  several 
months ;  as  long  an  interval  as  three  years  between  attacks  is 
recorded. 

Diagnosis.  Peritonitis  may  be  suspected  until  the  characteristic 
stools  occur. 

Dysentery  is  excluded  when  the  shreds  and  casts  of  membrane  ap- 
pear. 

Prognosis.  Favorable  as  to  life,  but  one  of  the  most  difficult  of 
diseases  to  eradicate. 


DISEASES   OF   THE   INTESTINAL  CANAL.  113 

Treatment.     The  diet  is   an  important  factor,  and   preference 
should  be  given  to  coarse  articles  instead  of  to  liquids. 

¥  or  the  pain  2ind  suffering,  opiu7}i  in  some  form  is  indicated,  the 
most  effective  being  a  hypodermic  injection  of  morphines  sulphas. 

For  cottstipation  during  a  paroxysm,  an  emulsion  of  oleimi  ricini 
with  terebiftihina  is  of  benefit.    Constipation  must  always  be  avoided. 

To  prevent  a  return  of  the  paroxysm,  either  liquor poiassii  arsenilis, 
n\^j-ij  (0.06-0.12  Cc),  before  meals,  or  hydrargyri  chloridtnn  corro 
sivum,  gr.  -^^  (o.ooi  Gm.),  three  times  a  day,  with  a  course  of  oleum 
morrhucB,  seems  to  answer  in  the  majority  of  cases.  Prof.  Da  Costa 
speaks  highly  oi  pix  liquida  in  some  form,  as  an  alterative  to  the 
mucous  membrane. 


CHOLERA  MORBUS. 

Synonyms.     Sporadic  cholera ;  English  cholera  ;  bilious  cholera. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  of  sudden  onset ;  charac- 
terized by  violent  abdominal  pains,  incessant  vomiting  and  purging, 
cold  surface,  rapid,  feeble  pulse,  spasmodic  contractions  of  the 
muscles  of  the  abdomen  and  extremities,  and  prostration. 

Causes.  A  disease  of  summer  and  early  autumn,  climatic  influ- 
ence being  an  important  factor.  Its  prevalence  during  certain 
seasons  seems  to  indicate  a  specific  cause.  Irritants  of  all  kinds, 
unripe  fruits  and  vegetables,  and  fermentation  of  food.  Probably  a 
ptomaine  poisoning. 

Pathological  Anatomy.  Cases  in  which  death  has  occurred 
within  a  few  hours  present  no  pathological  changes. 

Generally,  however,  the  gastro-intestinal  mucous  membrane  is 
congested  and  denuded  of  epithelium ;  the  solitary  and  Peyerian 
glands  are  swollen  and  prominent.  The  blood  is  thick,  and  dark  in 
color ;  the  kidneys  are  enlarged  and  congested ;  and  in  prolonged 
attacks  there  are  appearances  of  granular  changes  in  the  muscular 
system. 

Symptoms.  Onset  sudden  and  violent,  and,  unfortunately,  gen- 
erally after  midnight,  with  chilliness,  intense  nausea,  vomiting,  and 
purging,  accompanied  with  distressing  burning  or  tearing  abdominal 
pains  or  colic.    The  vomited  matter  at  first  consists  of  the  ordinary 


114  PRACT1C1-:    OF    MLUICINE. 

contents  of  the  stomach,  and  the  siooh  of  ordinary  ficces,  but  soon 
the  dischargees  by  vomit  and  stool  are  liquid,  wintish,  or  o{  ts.  green  or 
yellowish  tint;  if  the  attack  is  severe  or  protracted,  the  discharges 
are  of  the  "  rice-water''  character.  The  patient  is  rapidly  emaciated 
and  reduced  in  strength,  the  body  shrinks,  the  surface  is  cold  and 
covered  with  a  clammy  sweat,  and  the  pulse  is  small  and  feeble. 
Intense  thirst  is  present,  and  when  drink  is  given  it  is  at  once 
rejected. 

Aggravating  the  distress  of  the  patient  are  severe  cramps  of  the 
muscles,  and  especially  those  of  the  calves,  and  of  the  flexors  of  the 
thighs,  forearms,  fingers,  and  toes. 

Termination.  Mild  cases  often  terminate  favorably  without  treat- 
ment, the  patient  able  to  be  around  in  a  day  or  two,  although  weak. 

Severe  cases,  the  vomiting  and  purging  cease  after  some  hours,  but 
the  patient  remains  weak,  with  irritable  stomach  and  bowels  for  a 
week  or  two. 

Crave  cases,  the  true  cholera  type,  recover  from  the  prostration 
very  gradually  ;  reaction  coming  on  slowly  and  usually  passing  into  a 
typhoid  condition  of  some  weeks'  duration. 

Diagnosis.  Asiatic  cholera  and  cholera  morbus  are  easily  con- 
founded during  an  epidemic  of  the  former,  and  there  are  no  positive 
points  of  discrimination,  unless  the  comma  bacilli  oi  Koch  are  proven 
to  be  always  in  the  true  cholera  stools. 

Irritant  poisons,  such  as  tartar  emetic,  elaterium,  or  other  sub- 
stances, cause  vomiting  and  purging,  similar  to  cholera  morbus,  and 
are  only  discriminated  from  it  by  the  clinical  history  and  cause. 

Prognosis.  In  the  majority  of  cases  favorable.  The  mortality  is 
about  five  per  cent. 

Treatment.  At  once,  regardless  of  the  cause,  a  hypodermic  in- 
jection o{  mo7phincB  sulph.,  gr.  ^-^3  (0.008-0.022  Gm.),  and  atropines 
sulph.,  gr.  y^^  (0.00054  Gm.),  to  be  repeated  in  half  an  hour  if  no 
improvement;  for  patients  who  object  to  the  hypodermic  method, 
opium  in  some  form  by  the  mouth  or  rectum,  giving  the  preference 
to  the  liquid  preparations, 

Camphora  and  opium  combined  often  act  well,  or  the  "  enteric 
mixluie"  mentioned  on  page  iii,and  if  much  depression,  small 
doses  of  brattdy  or  dry  champagne. 

The  intense  thirst  must  not  be  gratified  by  the  use  of  liquids,  unless 
very  hot,  but  smaXX  pellets  of  ice  by  the  stomach  are  grateful. 


DISEASES   OF   THE   INTESTINAL  CANAL.  115 

If  the  vomiting  and  purging  continue,  make  use  of — 

U .      Bismuth,  subnit., gr-  xx  1. 3  Gm. 

Acid,  carbol., gr-  /^  -OI  Gm. 

Glycerini, TTLxx  1.3  Cc. 

AquK, fgiv  15.  Cc.  M. 

Every  hour,  in  water. 

If  the  vomiting  is  so  severe  that  no  opportunity  occurs  for  the 
medicament  to  come  in  contact  with  the  gastric  mucous  membrane, 
an  enema  of  chloral,  gr.  x-xv  (0.6-1  Gm.),  in  some  demulcent  with 
iinctiira  opii  deodorati,  tt\^x-xx  (0.6-1.2  Cc),  acts  often  like  magic 
in  quieting  the  distress  of  the  tortured  patient. 

The  closer  the  case  approaches  the  true  cholera  type,  the  more 
severe  are  the  muscidar  cramps,  and  their  treatment  demanded. 
Prof.  Da  Costa  suggests — 

R.     Chloral, .:;iv  15.       Gm. 

Ung.  petrolei, ^j  30.       Gm.  M, 

To  be  rubbed  over  the  affected  muscles. 

Dr.  Bartholow  suggests — 

R.     Chloral, ^iij  12.       Gm. 

Morphinae  sulph. , gr.  iv  .26  Gm. 

Aquae, f|j  30.       Cc.  M. 

SiG. — Twenty  minims,  hypodeiTaically,  repeated  p.  r.  n. 

Locally,  sinapis,  in  the  form  of  poultices  of  the  dry  powder,  should 
be  applied  to  the  abdomen,  or  terebinthina  stupes,  or  the  hot-water  bag. 

The  after  treatment  depends  upon  the  symptoms,  generally  an  acid 
mixture  and  a  regulated  diet,  with  tonic  doses  of  quinince  sulphas, 
are  indicated. 

ENTERO-COLITIS. 

Synonyms.  Inflammatory  diarrhoea  ;  ulcerative  entero-colitis. 
•  Definition.  A  catarrhal  inflammation  of  the  lower  portion  of  the 
small — ileum — and  the  upper  portion  of  the  large  intestines,  with  a 
great  tendency  to  ulceration  of  the  intestinal  glands  if  the  catarrh 
becomes  chronic  ;  characterized  by  moderate  fever,  nausea,  vomiting, 
diarrhoea,  swollen  abdomen,  pain,  and  emaciation.  A  common  dis- 
ease of  childhood. 

Causes.  Improper  and  indigestible  food  ;  summer  temperature  ; 
impure  air ;  uncleanliness  ;  exposure  to  cold  and  damp  air. 


116  PRACTICE    OF   MEDICINE. 

Most  commonly  a  disease  of  childhood. 

Forms.     .Acute  and  chronic. 

Pathological  Anatomy.  Acute  variety  ;  hyperaemia,  swelling, 
oedema,  and  softening  of  the  mucous  membrane  of  the  lower  portion 
of  the  small  and  the  upper  portion  of  the  large  intestines,  with  hyper- 
plasia of  the  intestinal  follicles,  their  excretory  follicles  enlarged  and 
tumid,  readily  distinguished  as  grayish  or  blackish  points  in  the  mid- 
dle of  the  glands  ;  the  patches  of  Peyer  are  also  enlarged,  tumefied, 
and  project  above  the  level  of  the  surrounding  mucous  membrane, 
the  orifices  of  the  follicles  appearing  as  dark  points;  these  patches 
often  have  an  ulcerated  appearance,  but  upon  closer  examination 
ulcers  are  not  discovered. 

Chronic  variety  ;  the  thickening  and  infiltration  have  extended  to 
the  submucous  and  muscular  coats,  followed  by  induration  of  the 
tissues,  so  that  the  walls  of  the  intestines  are  often  abnormally  rigid. 
Ulceration  occurs,  which  extends  through  the  entire  thickness  of  the 
membrane.  "  These  ulcers,  when  isolated,  are  from  one  to  one  and 
a  half  lines  in  diameter,  oval  or  circular  in  shape,  and  either  have 
sharp-cut  edges,  as  though  the  piece  of  mucous  membrane  had  been 
cut  out  with  a  punch,  or  the  mucous  membrane  bounding  them  is 
undermined."  The  small  ulcers  often  coalesce,  so  that  large,  irregu- 
lar ulcerated  patches  are  formed,  having  for  their  base  the  submucous 
or  muscular  coats,  and  have  a  grayish-white  color. 

The  mesenteric  glands  are  enlarged,  but  seldom,  if  ever,  undergo 
ulceration. 

Symptoms.  Acute  form  ;  may  develop  slowly,  with  restlessness 
and  fretfulness,  or  suddenly  \\\\.\\  feverishtiess ,  toss  of  appetite,  thirst, 
nausea,  moderate  voniitittg,  and  abdominal  pain  ;  or  diarrhooa  may 
be  the  first  indication  of  illness.  Regardless  of  the  character  of  the 
onset,  the  stools  should  present  the  characteristic  appearance  ;  they  are 
semi-fiuid,  heterogeneous,  ^r<fi?«/j//,  acid,  mixed  with  yellowish  frag- 
inetits  of  ordinary  fasces,  and  undigested  casein,  termed  the  "  chopped 
spinach  "  stools.  The  abdomen  is  enlarged  and  tender.  An  irregular 
temperature  record  may  occur  with  increased  frequency  of  the  pulse. 

Emaciation  is  marked  in  proportion  to  the  severity  of  the  symp- 
toms ;  in  marked  cases  the  child  is  reduced  to  a  condition  of  the 
greatest  debility  within  a  few  days. 

Chro7iic  forjn,  or  ulcerative  enterocolitis,  usually  follows  the  acute 
form,  the  character  of  the  symptoms  being  less  severe,  but  decidedly 


DISEASES  OF   THE  INTESTINAL  CANAL,  117 

persistent :  the  strength  fails,  the  temper  is  very  irritable ;  the  com- 
plexion grows  dark,  sallow,  and  unhealthy,  the  skin  dry  and  harsh, 
and,  in  consequence  of  the  marked  emaciation,  either  hangs  in  folds 
around  the  shrunken  limbs  or  is  drawn  tightly  over  the  joints  ;  the 
abdomen  is  enlarged  and  tender,  the  stools  numbering  from  six  to  a 
dozen  during  the  day  and  night,  consisting  of  the  products  of  an  im- 
perfect digestion  mixed  with  mucus,  serum,  pus,  and  oftentimes  blood, 
having  a  semi-fluid  consistency,  and  an  extremely  offensive  odor. 
Ulcerative  stomatitis  is  a  frequent  complication  adding  to  the  dis- 
comfort of  the  patient.  An  irregular  temperature  record  may  occur 
with  increased  frequency  of  the  pulse. 

Duration.  Acute  form,  from  ten  days  to  about  two  weeks,  sub- 
siding gradually  ;  chronic  form,  from  one  to  two  or  three  months,  or 
even  longer. 

Diagnosis.  The  acute  form  can  hardly  be  mistaken  for  any 
other  condition,  if  the  characteristic  stools  and  other  abdominal  symp- 
toms are  present.  The  chronic  form  has  been  frequently  mistaken 
for  the  diarrhoea  of  tuberculosis,  an  error  that  can  hardly  occur  if  a 
physical  examination  of  the  chest  has  been  made,  as  well  as  micro- 
scopical examination  of  the  stools. 

Prognosis.  Always  a  very  serious  malady,  and  proves  fatal  if  it 
attacks  the  weak  during  midsummer,  or  when  surrounded  by  unfavor- 
able hygienic  conditions ;  in  vigorous  children,  who  have  passed 
through  their  first  dentition,  the  prognosis  is  quite  favorable. 

Treatment.  For  the  acute  form,  restricting  the  amount  of  food 
for  the  first  few  days  is  of  importance.  Fresh,  pure  air,  cleanliness, 
and  rest  are  also  of  great  importance. 

Any  one  of  the  following  formulae  may  be  used  with  advantage ; 

R.     Salol, g^'  ij  '13  Gm. 

Bismuthi  subnit., gr.  v  .32  Gm. 

Ft.  chart. 

SiG. — Such  a  powder  every  two  hours. 

Or— 

R .     Hydrargyri  chlor.  mite,     .    .    .    .   gr.  ss  .032  Gm. 

Pulv.  ipecac,      gr.  ss  .032  Gm. 

Pulv.  opii, gr.  ss  .032  Gm. 

CretJe  pr^parat., gr.  xx  1. 3      Gm.         M. 

Ft.  chart.    No.  xij. 

SiG. — One  every  two  or  three  hours,  to  child  of  one  year. 

Many  cases  do  well  with  pulvis  kino  comp.,  others  with  minute 


118  PRACTICE    OF    MEDICINE. 

doses,  frequently  repeated,  of  aa'dum  lacticum,  and  many  others  with 
bismnihi subniiras,  gr.  x-xv  (0.6-1  Gm.),  in  milk,  every  few  hours. 
The  following  is  a  good  comljination  ; 

R.     Bismuth!  subnit., .^^  iij  1 2.  Gm. 

Tinct.  kino, ^^'^^  ^^'  ^^' 

Tinct.  opii  camphorat.,      .    .    .    .  f  siss  45.  Cc. 

Mist,  cretse 5iij  90.  Cc.  M. 

SiG. — Tablespoonful  every  few  hours. 

Locally,  warmth  to  the  abdomen,  with  mustard,  turpentine  stupes, 
or  the  spice  poultice,  made  as  follows  :  cloves,  allspice,  cinnaviou,  and 
anise  seeds,  each  half  an  ounce  (15.6  Gm.),  pounded  (not  powdered) 
in  a  mortar,  and  placed  between  two  pieces  of  coarse  flannel  about 
six  inches  square  and  quilted  in  ;  soak  this  for  a  few  minutes  in  hot 
brandy  or  hot  whisky  and  water,  equal  parts,  and  apply  to  the  abdo- 
men, heating  again  as  it  becomes  cool. 

Chronic  entero-colitis.  Few  conditions  will  tax  the  skill  and 
patience  of  the  physician  to  the  same  degree. 

First  and  foremost  the  diet  must  be  carefully  regulated.  Milk 
,  alone,  or  predigested,  or  with  lime-water,  in  the  majority  of  cases  is  the 
best  article  of  diet.  Should  it  disagree,  then  recourse  must  be  had  to 
some  of  the  prepared  foods,  such  as  Mellin's,  Horlick's,  Ridge's, 
Blair's  prepared  wheat,  Liquid  Peptonoids,  or  Eskay's  albuminized 
food,  or  other  prepared  foods,  often  the  one  agreeing  with  one 
patient  will  not  agree  with  another. 

After  caring  for  the  diet,  then  the  hygiene  of  the  patient  requires 
attention.  Cleanliness,  such  as  daily  warm  baths,  often  adding  with 
advantage  sea-salt.  Rest  in  bed  for  an  hour  or  more  after  meals  if 
the  patient  cannot  be  kept  continually  in  bed.  The  air  of  the  room 
should  be  fresh  and  pure. 

Among  drugs  may  be  mentioned  bismuthum  z.ndi pepsinutn  or  sah- 
cinutn.     Or — 

R .     Argenti  nitrat. , gr.  j  .065  Gm. 

Acid,  nitric,  dil., TTLxv  I.         Cc. 

Mucil.  acaciae, f.S^s  I5-         Cc. 

Aq.  cinnamomi, ad  f^iij  ad     90.         Cc.  M. 

SiG. — Teaspoonful,  diluted,  every  three  or  four  hours. 

Or— 

R.     Acidi  carbolici gr.  yj-J  .005-008  Gm 

TincturjE  iodi, 'UJ""'J  .06-.  12      Cc. 

Afjure  menthK, fjj  4.                  Cc.     M. 

SiG. — Every  three  or  four  hours. 


DISEASKS    OF   THE   INTESTINAL   CANAL.  119 

Or— 

R.     Tinct.  calumbge,      f  3  iij  12.     Cc. 

Liq.  ferri  nitratis, TTLxxx  2.     Cc. 

Syrupi  zingib. ,    ....     q.  s.  adfgiij  ad     90.     Cc.               M. 

SiG. — One    or  two  teaspoonfuls,    according  to   age,    every  three  or  four 
hours,  diluted. 

Or— 

R.      Quinince  muriat., gr.  xxv  1.6    Gm. 

Acid,  tannici, gr.  x  .6    Gm. 

Syr.  limonis, f  3  ij  8.       Cc. 

Aq.  chloroformi, ad  f^iij  ad       12.       Cc.            M. 

SiG. — Teaspoonful  every  two  hours. 


CHOLERA  INFANTUM. 

Synonyms.     Choleriform  diarrhoea ;  summer  complaint. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  together  with  an  irritation 
of  the  sympathetic  nervous  system,  occurring  in  children  during  their 
first  dentition  ;  characterized  by  severe  colicky  pains,  vomiting,  purg- 
ing, febrile  reaction,  and  prostration. 

Cause.  Age.  There  is  no  other  disease  of  the  intestinal  canal 
showing  the  evidence  of  infectious  origin  so  strongly  as  typical  attacks 
of  cholera  infantum.  Bad  hygiene,  or,  as  it  is  now  entitled,  "  civic 
malaria";  continuous  high  temperature  ;  improper  food  ;  dentition; 
constitutional,  as  in  the  feeble,  delicate,  nervous,  or  irritable. 

Pathological  Anatomy.  Resembles  closely,  if  not  identical 
with,  the  phenomena  of  catarrhal  gastritis  and  enteritis,  together  with 
a  powerful  irritation  of  the  fibres  of  the  sympathetic  nervous  system. 

Symptoms.  The  onset  is  sudden  in  a  child  previously  well,  or 
in  a  child  suffering  from  a  bowel  affection. 

Begins  with  vomiting, purging,  ahdominal  pain,  fever,  rapidpulse, 
and  intense  thirst. 

The  vomited  matter  is  partly  digested  food,  sero-mucus,  and  finally- 
bilious,  and  is  accompanied  with  distressing  retching.  The  thirst  is 
a  marked  phenomenon  of  the  disease,  and  ice  and  water  will  be 
taken  incessantly,  although  rejected  only  a  few  moments  after. 

I  he  stools  are  first  partly  fscal,  but  soon  watery  or  serous,  soaking 


120  PRACTICE    OF    MEDICINE. 

the  clothing,  leaving  a  faint  greenish  or  yellowish  stain  ;  their  odor 
is  musty,  at  times  fetid  ;  their  number  is  from  ten  to  twenty  in  the 
day.  Pains  precede  the  vomiting  and  purging,  colicky  in  char- 
acter. 

'\\\&  fever  begins  at  once,  the  temperature  varying  from  ioi°  to  105°, 
with  morning  remissions.  The  pulse  is  rapid  and  feeble,  ranging 
from  130  to  160  beats. 

These  symptoms  continue  but  a  few  hours,  before  rapid  wasting 
ensues,  the  body  shrinks,  the  eyes  are  sunken  and  partly  closed,  the 
mouth  partly  open,  the  lips  dry,  cracked,  and  bleeding.  The  child, 
at  first  irritable  and  restless,  passes  into  a  semi-comatose  condition, 
the  pulse  becoming  more  and  more  feeble  ;  the  surface  has  a  clammy 
coldness,  the  contracted  pupils  not  responding  to  light,  and  the 
stupor  deepens,  death  soon  following,  or  the  symptoms  slowly  ame- 
liorate, convalescence  being  slow  and  tedious. 

Diagnosis.  The  ejttero  colitis  or  inflammatory  diarrhoea  of  child- 
hood is  constantly  being  mistaken  for  cholera  infantum.  The  symp- 
toms of  the  former  are  :  gradual  onset,  with  freifulness,  loss  of  appe- 
tite, fei'erishness,  nausea,  and  moderate  vomiting,  soon  followed  by 
diarrhoea,  the  stools  being  semi-fluid,  greenish,  mixed  with  yellowish 
particles  of  fzeces  and  undigested  casein,  with  a  sour  odor,  the 
"chopped  spinach"  stools,  the  abdomen  distended  and  tender, 
moderateyi'7'4'r  and  thirst,  and  having  a  duration  of  about  two  weeks. 

Prognosis.  Difficult  to  predict  the  result,  and  so  care  must  be 
exercised  in  giving  a  prognosis.  The  duration  of  the  choleraic  symp- 
toms is  short,  under  five  days,  but  relapses  are  common,  and  the 
sequelae  are  protracted. 

Treatment. — The  result  of  any  mode  of  treatment  for  true  cases 
of  cholera  infantum  is  unsatisfactory.  Holt  urges  attention  to  the 
toxic  nature  of  the  disease,  and  suggests  following  indications  for 
treatment :  Empty  stomach  and  intestines  by  stomach  washing  and 
intestinal  irrigation  ;  neutralize  the  cardiac  and  nervous  poison  by 
hypodermics  of  morphia  and  atropia  ;  supply  the  fluid  drain  by 
hypodermoclysis  of  normal  salt  solution,  and  its  intestinal  use,  and 
reduction  of  temperature  by  the  graduated  cooling  bath  and  ice-cap  to 
the  head  and  bold  stimulation.  Change  of  air  of  the  greatest  benefit. 
Restricted  diet,  and  particularly  for  first  few  days,  using  brandy,  T\v-x 
(0.3-0.6  Cc),  in  barley  luater  at  hourly  intervals. 

For  the  vomiting,  large  doses  of  bismuthum ;  or  chloral,  ^r.  j-iij 


DISEASES   OF   THE    INTESTINAL   CANAL.  121 

(0.065-0.21  Gm.),  by  mouth  in  demulcent,  or  double  the  amount  by 
the  rectum,  or  one  of  the  following : 

U.     Bismuth,  subnit. , ^i]  8.         Gm. 

Acid,  carbolici, gr.  j  .065  Gm. 

Mist,  acaciae, 

Aq.  menth.  pip., a^  f oj  ^  30-         Cc.  M. 

SiG. — Teaspoonful  every  half-hour,  hour,  or  two  hours. 

Or— 

R .     Hydrargyri  chlor.  mit.,      .    .    .    gr.  ^V  •'^S     G™- 

Bismuth,  subnit., gr.  ij-v  -IS-'S  Gm.     M. 

SiG. — A  powder  every  half  hour. 

Good  results  are  reported  from  bistnuihi  salicylas,  gr.  ij  (0.13  Gm.), 
with  sugar  of  milk  every  hour  or  two,  or  salol,  gr.  j-ij  (0.065-0.13  Gm.), 
every  two  or  four  hours. 

If  the  fever  is  high,  sponging  with  alcohol  and  water,  the  cold 
pack,  or  the  cool  bath  can  be  used  first,  gradually  reducing  its  tem- 
perature, and  afterwards  using  stimulants. 

For  depression,  regulated  nursing,  and  feeding  every  two  hours,  and 
water  or  ice  to  quench  the  intense  thirst,  and  cognac  brandy,  Tt\^v-x 
(0.3-0.6  Cc),  every  hour  or  two,  in  water,  by  mouth  or  in  warm 
enema. 

Locally :  over  epigastrium,  mustard  or  a  spice  poultice,  or  turpen- 
tine stupes. 

If  the  nervous  symptoms  become  aggravated,  small  dose  oi  potassii 
bromidttm  or  valerian,  which  "  reduces  the  reflex  excitability,  motil- 
ity, and  sensibility,"  is  indicated. 


ACUTE  DYSENTERY. 

Synonyms.     Colitis  ;  ulcerative  colitis  ;  bl9ody  flux. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  large  intestines  ;  either  catarrhal  or  croupous  in  character,  followed 
in  some  cases  with  ulceration,  characterized  by  fever,  tormina,  tenes- 
mus, and  frequent,  small,  mucous,  and  bloody  stools. 

It  occurs  either  sporadically ,  endemically,  or  epidetnically. 

Four  clinical  forms  are  described  :  acute  catarrhal  ;  amoebic  ot 
tropical  ;  croupous  or  diphtheritic  ;  chronic  dysentery. 


122  PRACTICE    OH-    MKDICINE. 

Causes.  Sporadic,  endemic,  or  caiarr/ta/ dysentery  prevails  most 
extensively  in  the  summer  and  early  autumn  months.  All  forms  of 
colitis  are  of  bacterial  origin.  Sudden  atmospheric  changes,  such  as 
hot  days  and  cool  nights.  Malaria  has  some  connection  with  its 
causation.  Errors  in  diet  not  a  cause.  The  drinking  water  may  b<- 
the  means  by  which  the  poison  gains  entrance  to  the  system. 

Amoebic  or  tropical  dysentery,  characterized  by  the  presence  in  the 
stools  of  the  Amceba  coli  {\J6ic\\)  or  Amoeba  dysente>iia  (Councilman 
and  Lafleur).     This  variety  is  often  epidemic  in  the  tropics. 

Croupous  or  diphtheritic  dysentery  is  often  epidemic  ;  frequently 
occurs  as  a  terminal  event  in  acute  and  chronic  diseases.  The  causes 
are  much  those  of  the  acute  catarrhal  form,  acting  upon  a  depressed 
system.     The  Ainasba  co/i  ma.y  be  seen  in  the  stools. 

Dysentery  is  not  contagious,  but  is  infectious. 

Pathological  Anatomy.  Catarrhal  dysentery ;  congestion, 
swelling,  and  oedema  of  the  mucous  membrane  and  submucous 
tissue  of  the  large  bowel,  with  an  over-production  of  mucus  ;  the  fol- 
licles are  enlarged,  from  retention  of  their  contents,  the  result  of  the 
swelling  ;  the  congested  vessels  often  rupture  ;  the  mucous  mem- 
brane softens  in  patches,  and  is  detached,  forming  ulcers.  Recovery 
follows,  if  the  destruction  of  tissue  is  small,  smooth  cicatrices,  minus 
gland  structure,  marking  the  site. 

Amcebic  or  tropical  dysentery,  the  lesions  are  also  in  the  large  intes- 
tines and  sometimes  in  the  lower  portion  of  the  ileum.  Abscess  of 
the  liver  is  a  frequent  complication. 

"The  lesions  consist  of  ulceration,  produced  by  preceding  infiltra- 
tion, general  or  local,  of  the  submucosa,  the  general  infiltration  being 
due  to  an  oedematous  condition,  the  local  to  multiplication  of  the 
fixed  cells  of  the  tissue.  In  the  earliest  stages  these  local  infiltrations 
appear  as  hemispherical  elevations  above  the  general  level  of  tlie 
mucosa.  The  mucous  membrane  over  these  soon  become  necrotic 
and  is  cast  off,  exposing  the  infiltrated  submucous  tissue  as  a 
grayish-yellow,  gelatinous  mass,  which  at  first  forms  the  floor  of  the 
ulcer,  but  is  subsequently  cast  off  as  a  slough."     (Osier.) 

Croupous  or  diphtheritic  dysentery  begins  with  intense  congestion, 
swelling,  and  oedema  of  the  mucous  and  submucous  tissue,  with 
extravasations  of  blood  and  the  whole  mucous  membrane  covered 
with  a  firm,  fibrinofts  exudation  ;  the  mucous  membrane  softens  and 
sloughs,  leaving  large  ulcers  and  gangrenous  spots.      If  recovery 


DISEASES   OF   THE   INTESTINAL   CANAL.  123 

occur,  large  cicatrices  form,  which  narrow  the  calibre  of  the  intestinal 
tube. 

The  mesenteric  glands  enlarge,  soften ,  and  abscesses  form  in  them  ; 
the  liver  becomes  the  seat  of  small  abscesses,  from  embolic  obstruc- 
tion of  the  radicles  of  the  portal  vein  ;  the  heart  muscles  are  flabby 
and  more  or  less  fatty. 

Symptoms.  Catarrhal  fortn  begins  gradually,  with  diarrham, 
loss  of  appetite,  nausea,  and  very  slight  ftver,  vihich.  continues  for 
two  or  three  days,  when  the  true  dysenteric  symptoms  develop,  to  wit, 
paiti  on  pressure  along  the  transverse  and  descending  colon,  tormina 
or  colicky  pains  about  the  umbilicus,  burjiingpaiji  in  the  rectum,  with 
the  sensation  of  thie  presence  of  a  foreign  body  and  a  constant  desire 
to  expel  it,  ox  tenesmus ;  the  stools  for  the  first  day  or  two  contain 
more  or  less  faecal  matter,  but  they  soon  change  to  a  grayish, 
tough,  trafisparent  mticus,  containing  more  or  less  blood  and  /z/j/ 
dnrmgiYiQ  tonnina,  nausea  and  vomiting  may  occur;  the  urine  is 
scanty  and  high-colored  ;  the  number  of  stools  varies  from  five  to 
twenty  or  more  in  the  twenty-four  hours. 

The  duration  is  about  07ie  iveek,  the  patient  being  much  emaciated 
and  enfeebled. 

Amcebicform  begins  gradually  as  the  catarrhal  form,  or  gradually  as 
an  increasing  diarrhoea.  Soon  the  stools  become  characteristic  of  the 
variety  of  the  attack,  he.\ng  frequent,  bloody,  mucoid,  but  very  fluid  ; 
as  the  disease  progresses,  the  stools  h&covne yelloivish-gray3.nd.  liquid, 
containing  mucus,  sometimes  bloody.  The  number  of  stools  varies 
from  six  to  a  dozen  or  more  in  a  day.  Actively  moving  amoeba  are 
found  in  the  stools,  disappearing  as  the  stools  become  formed.  Fever 
may  or  may  not  be  present,  or  may  come  and  go.  Abdominal 
pain  and  tenesmus  are  present  in  the  majority  of  cases. 

The  loss  of  flesh  and  strength  is  marked.  Abscess  of  liver  and 
lungs  are  frequent  and  grave  complications. 

Duration  from  six  to  twelve  weeks  ;  recovery  tedious,  owing  to  anae- 
mia and  loss  of  flesh. 

In  every  endemic  or  epidemic  of  dysentery  a  number  of  amcebic 
cases  will  occur.  During  the  past  three  years  I  have  seen  probably 
two  hundred  cases  of  dysentery,  beginning  as  catarrhal,  but  in  the 
midst  of  the  endemic  a  number  of  amcebic  cases  occurred,  the  con- 
valescence long  outlasting  the  catarrhal  variety. 

The  croupous  or  diphtheritic  form  sets  in  suddenly,  the  stools  being 


IL'4  PRACTICE    OF    MEDICINE. 

more  frequent,  containing  more  blood  Z-nd.  pus,  wxiYi  patches  of  »it-m- 
brane,  even  casts  of  the  bowel,  together  with  more  or  \tss  t^augrenous 
mucous  membrane  ;  nausea,  voviiting,  and  great  prostration,  cold 
skin,  feeble  pulse,  and  emaciation  with  anxious  expression,  the  odor 
surrounding  the  patient  h€\r\<g  fetid. 

The  occurrence  of  this  form  as  a  termination  of  Bright's  disease, 
lung  and  heart  diseases,  must  be  borne  in  mind. 

The  duration  of  the  grave  symptoms  is  three  or  four  days,  when 
collapse  and  death  occur,  or  slow  convalescence  begins,  continuing 
for  weeks. 

Chronic  Dysentery.  This  is  really  a  continuation  of  the  acute 
disease,  the  symptoms  continuing  the  result  of  the  ulcerated  mucous 
membrane,  or  the  cystic  degeneration  of  the  glandular  elements  of 
the  large  gut  (Woodward).  Rarely,  dysentery  develops  subacutely, 
and  thus  is  almost  chronic  from  the  beginning.  There  is  seldom  a 
characteristic  stool,  little  colicky  pain,  and  little  or  no  tenesmus,  but  a 
progressive  loss  of  flesh  with  loose  bowels,  the  stools  containing  mucus, 
little  or  no  blood,  undigested  food,  and  are  frothy.  The  number  varies 
from  two  to  a  dozen  in  a  day.  Acute  exacerbations  are  frequent. 
Duration,  often  months  or  years. 

Complications.  Peritonitis;  hepatic  abscesses ;  phlebitis  of  the 
intestinal  veins;  intestinal  perforation. 

Diagnosis.   Enteritis  lacks  the  tenesmus  and  characteristic  stools. 

Peritonitis,  when  idiopathic,  shows  higher  temperature,  greater 
tenderness,  and  constipation. 

Chronic  dysentery  is  difficult  to  distinguish  from  chronic  diarrhoea. 

Prognosis.     Catarrhal  form  favorable,  save  in  those  debilitated. 

Amccbic  form:  the  mortality  is  higher  than  in  catarrhal  form,  and 
in  favorable  cases  the  convalescence  is  slow. 

Croupous  form  :  the  prognosis  is  always  grave,  for  if  recovery  does 
occur,  the  bowel  may  be  crippled  from  loss  of  structure,  or  from  nar- 
rowing of  its  calibre,  the  results  of  cicatrices. 

Treatment.  Keeping  in  mind  the  following  dictum  of  Osier, 
no  case  of  dysentery,  however  mild,  should  be  lightly  considered  : 
"  Dysentery  is  one  of  the  four  great  epidemic  diseases  of  the  world. 
In  the  tropics  it  destroys  more  lives  than  cholera,  and  it  has  been 
more  fatal  to  armies  than  powder  and  shot." 

The  patient  should  be  confined  to  bed  in  even  the  mildest  attack, 
and  the  stools  removed  at  once  and  disinfected.    In  fact-  the  bed-pan 


DISEASES   OF  THE   INTESTINAL   CANAL.  125 

or  Other  vessels  should  constantly  contain  a  solution  oi  ferrous  sul- 
phate (copperas)  sufficient  to  cover  the  expected  stool. 

The  diet  to  be  of  the  most  nourishing  yet  bland  character,  adding 
stimulants  if  much  prostration. 

The  most  frequently  used  drug,  and  in  many  cases  by  far  the  best, 
is  opium,  alone  or  combined  with  one  or  more  astringents : 

R .     Ext.  opii,     . gr.  ss  .032  Gm. 

Plumbi  acetat., gr-  ij  -IS    Gm. 

Every  two  hours. 

Or— 

R .     Pulv.  opii, gr.  ss  .032  Gm. 

riumbi  acetat., gr.  ij  .13    Gm. 

Pulv.  ipecac, gr-  X  •°^^  Gm. 

Every  two  hours,  until  character  of  stools  change. 

I  have  frequently  seen  the  character  of  the  stools  change  within 
twenty-four  hours  with  the  following,  which  I  call  Mistura  enterica, 
viz. : 

R.     Acid,  sulph.  dil., >  f.l  ss  15.  Co. 

Tinct.  opii  deodorat., f^^j  30.  Co. 

Spts.  camphoras, f_^j  30.  Cc. 

Tinct.  capsici, f^ss  15.  Cc. 

Spts.  chloroformi, f^ss  15.  Cc. 

Spts.  vini  gallici,    ........  fgiss  45.  Cc. 

SiG. — One  teaspoonful  every  two  or  three  hours,  diluted. 

In  more  than  one  instance  I  have  seen  a  severe  attack  of  acute 
dysentery  succumb  to  morphines  sulphas,  gr.  X~/^  (0.016-0.032  Gm.), 
three  or  four  times  daily  hypodermically,  within  three  or  four  days. 
For  the  intense  tormina  and  tenesmus  no  remedy  is  comparable  with 
morphia  by  the  hypodermic  method. 

In  strong  young  individuals  the  very  best  prescription  possible  is — 

U .     Magnesii  sulph , ^j  4.     Gm. 

Acid,  sulph.  dil., n^x  .6  Cc. 

Tinct.  opii  deodorat., rrLx  .6  Cc. 

Aquse  chloroformi,      ....    ad  5  ij  ad     8.    Cc.  M. 

Every  two  or  three  hours,  until  faeces  appear  in  the  stools,  when 
small  doses  of  opium  and  quinines  sulphas  may  be  used. 

Bismuthi  subnii.,  gr.  xxx  (2  Gm.),  every  two  or  three  hours,  01 


126  PRACTICE   OF    MEDICINE. 

bismuthi salicylas,  gr.  xx  (1.3  Gm.),  every  two  or  three  hours,  are  often 
successful. 

Ur.  Loomis  speaks  strongly  of  ipecacuanha,  gr.  \i  (0.016  Gin.), 
every  half-hour,  with  sufficient  opium  to  secure  quietness.  The 
large  doses  of  ipecacuanha  recommended  I  have  had  no  experience 
with. 

Ringer  recommends  hydrargyri  chloridiim  corrosivuin,  gr.  yj^ 
(0.00065  Gm.),  every  hour  or  two,  which  "  rarely  fails  to  free  the 
stools  from  blood  and  slime,  although  in  some  cases  a  diarrhoea  of  a 
different  character  may  continue  for  a  short  time  longer." 

In  children  the  following  combination  is  successful  : 

B .     Pulv.  ipecacuanhre, S^-  H  -O'^        G™- 

Bismuth,  subnit., gr.  v-x  .32-.65  Cim. 

Cretae  praep. gr-  iij  -2  Gm.  M. 

SiG. — Every  two  hours. 

Washing  out  the  rectum  with  either  tepid,  hot,  cold,  or  iced  water, 
as  suggested  by  Prof.  Da  Costa,  adds  greatly  to  the  patient's  comfort 
and  to  the  decrease  of  the  inflammatory  process.  Ice  suppositories 
are  soothing  and  relieve  the  tenesmus  and  rectal  pain. 

A  one  or  two  per  cent,  solution  of  creolin  (one-half  pint)  as  an 
enema  often  rapidly  lessens  the  number  of  stools  and  the  tenesmus. 
Dr.  H.  C.  Wood  recommends  iodoform  suppositories. 

"  In  the  cases  of  amoebic  dysentery  we  have  been  using  at  the 
Johns  Hopkins  Hospital,  with  great  benefit,  warm  injections  of  quinine 
in  strength  of  i  to  5000,  i  to  2500,  and  i  to  1000.  The  amoebae  are 
rapidly  destroyed  by  it."     (Osier.) 

I  have  met  over  five  hundred  cases  of  acute  dysentery  during  the 
past  six  years,  and  have  nearly  always  been  successful  with  nitclein- 
Aulde,  gr.  j  (0.065  Gm.),  or  Tr^j-v  (006-0.3  Cc),  every  hour  until 
the  character  of  the  stools  change,  when  the  interval  of  the  dose  is 
widened  to  two  or  three  hours  and  bismuthum  or  the  foregoing 
mistura  enterica  added. 

Locally,  poultices,  stupes,  and  the  water  bag  do  no  good,  but  if 
they  are  agreeable  to  the  patient  they  may  be  allowed,  as  they  do 
no  harm, 

CJu-onic  dysentery.  A  carefully  selected  but  nourishing  diet,  change 
of  scene,  and  some  of  the  following  remedies  :  Bismuthum  subnitrat., 
gr.  XXX  (2  Gm.),  t.  i.  d.  ;  terebinthina,  n\,x  (0.6  Cc),  every  three  or  four 


DISEASES   OF  THE   INTESTINAL  CANAL.  127 

hours;  argenii  nitras ,  gr.  yi-yi  (0.008-0.022  Gm.),  three  or  four  times 
daily  ;  or  B .  Cupri  sulphas,  gr.  ^  (o.oi  i  Gm.)  ;  ext.  opii,  aq.,  gr.  X~K 
(0.016-0.032  Gm,)  ;  ext.  nucis  vomicce,  gr.  3^  (o.oii  Gm.),  in  pill,  four 
times  daily. 

Chronic  dysentery  is  sometimes  protracted  by  a  trifling  patch  of  in- 
flammation or  ulceration  in  the  rectum  or  sigrnoid  flexure,  or  a  relaxed 
condition  of  the  mucous  membrane  of  the  rectum,  and  of  the  hemor- 
rhoidal vessels.  There  occur  two  or  three  loose  stools  in  the  morn- 
ing, a  mucous  dysentery,  and  then  a  comparatively  comfortable  day. 
The  stools  are  preceded  by  some  colicky  pain  across  the  lower  part 
of  the  abdomen  and  in  the  line  of  the  large  bowel.  The  general 
condition,  other  than  the  anaemia  and  weakness,  of  the  patient  is 
good.  Drugs  by  the  mouth  are  useless  to  control  these  cases  ;  the 
medication  must  be  made  directly  to  the  diseased  part.  Injections  of 
argenii  nitras,  gr.  v  to  xx  or  xxx  (0.32-1.3-2  Gm.),  to  the  pint,  are 
curative  ;  the  silver  may  be  combined  with  opium  (R.  Argent,  nitrat., 
gr,  j  (0.065  Gm.) ;  tinct,  opii  deodorat,,  ttLxv  (i  Cc.)  ;  aquge  amyli, 
f|iv(i2o  Cc)  ;  M.), 

During  the  convalescence  from  all  varieties  of  dysentery,  tonics 
are  indicated  (R.  Strychninae  sulph.,  gr.  yi  (0-032  Gm.) ;  acid  hydro- 
chlorici  dil.,  f3>j  (8  Cc.) ;  tinct.  gentian  comp,,  q.  s.  ad  f^iv  (120 
Cc.)  ;  M.  S. — One  teaspoonful  before  meals  in  water.  A  course 
of  oleum  niorrhiKs  with  syr.  calcii  lactophosphatis,  should  be  used 
if  much  emaciation. 


TYPHLITIS. 

Synonyms.     Inflammation   of  the  csecum  ;  typhlitis  stercoralis. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  csecum  and  ascending  colon  ;  characterized  by  pain,  tender- 
ness, constipation,  and  in  certain  cases  a  characteristic  vomiting. 

Causes.  I  do  not  believe  the  term  "  typhlitis  "  is  to  be  sup- 
planted by  the  term  appendicitis ;  I  am  convinced  there  are  two 
conditions  having  some  symptoms  in  common.  In  a  majority  of 
instances  typhlitis  is  mechanical,  due  to  the  accumulation  of  fasces 
in  the  csecum. 

Pathological  Anatomy.  Similar  to  the  catarrhal  inflammation 
of  dysentery. 

Symptoms.     Pain  and  tenderness  in  the  right  iliac  fossa   and 


128  PRACTICE    OF    MEDICINE. 

along  the  ascending  colon,  with  some  pominence  of  this  region  ;  the 
bowels  are  distended  with  gas  (jneteoriivt)  and  are  usually  consti- 
pated, or  small  liquid  stools  may  occur  from  time  to  time,  due  to  the 
accumulation  of  hardened  Acces  in  the  sacculated  periphery  of  the 
caecum,  leaving  a  central  canal  through  which  the  liquid  contents  of 
the  upper  bowel  can  pass. 

In  severe  cases,  "the  local  pain,  tenderness,  and  swellin*^  are 
greater;  there  are  impaction  oi  faces  and  no  movements  or  flatus. 
There  are  decided  fever,  restiessjtess,  and  also  nausea  and  vomiting. 
The  vomited  matters,  at  first  the  contents  of  the  stomach,  then  of 
the  duodenum,  with  bilious  matter,  and  ultimately,  if  the  impaction 
persists,  of  material  having  the  odor  of  faeces.  With  these  symp- 
toms occur  great  depression  of  the  vital  powers.  Peritonitis  is 
finally  developed  by  contiguity  of  tissue  or  by  rupture  of  the 
bowel." 

The  temperature  in  even  mild  cases  is  one  or  two  degrees  above 
the  normal  and  in  a  fair  number  an  eruption  is  seen  upon  the 
abdomen,  consisting  of  one  or  two  dark  red  spots  the  size  of  a  pin- 
head,  which  are  of  short  life  and  disappear  on  pressure. 

Duration.  The  mild  form  lasts  about  one  week.  The  severe 
form  may  terminate  in  subacute  peritonitis,  continuing  about  two 
weeks. 

Diagnosis.  The  mild  fonn  is  distinguished  from  other  intestinal 
affections  by  the  localized  pain,  tenderness,  and  prominence,  and  the 
constipation. 

The  severe  form  can  only  be  distinguished  from  the  other  forms  of 
intestinal  obstruction  by  the  history  of  the  case  and  attack,  and  the 
results  of  treatment. 

Prognosis.  Mild  form  favorable.  Severe  form  grave,  although 
not  necessarily  fatal. 

Treatment.  The  patient  should  be  kept  in  bed,  and  placed  on  a 
strictly  milk  diet  in  very  limited  amounts. 

Two  indications  are  to  be  met,  which  are  seemingly  opposed  to  each 
other  :  first,  the  removal  of  the  accumulation  of  faeces,  which  in  the 
majority  of  cases  has  caused  and  still  maintains  the  inflammation ; 
second,  to  retard  the  inflammation  resulting  from  the  presence  of  the 
fecal  mass. 

If  the  pain  and  suffering  be  intense,  at  once  administer  a  hypo- 
dermic injection  of  morphines  sulphas. 


DISEASES   OF   THE    INTESTINAL   CANAL.  129 

The  two  indications  above  named  are  met  by  the  use  of  the  fol- 
lowing : 

R.     Magnesii  sulph., ^^xij  48.  Gm. 

Acid,  sulphuiici  dil.,      .    ,    .    .  f^ij  8.  Cc. 

Tinct.  opii  deodorat.,      .    .    .    .  fgiv  15.  Cc. 

Spts.  chloroformi, f^ij  8.  Cc. 

Aquse  menth.  pip. ,    .    .  q.  s.  ad  (^  iij  ad     90.  Cc.           M. 
SiG. — One  teaspoonful  every  hour,  dikited. 

If  it  be  true  that  calomel  has  a  specific  action  upon  the  lower  por- 
tion of  the  small  bowel,  increasing  the  secretion  from  the  glands 
located  there,  then  the  following  should  be  useful : 

U .     Hydrargyri  chlor.  mite,     .    .    .  gr.  ij  .  13    Gm. 

Sodii  bicarb., gr.  xx  1.3      Gm. 

Sacc.  lac, gr.  xxx  2.         Gm. 

Ft.  chart.  No.  x. 

SiG. — One  every  hour  till  twelve  taken,  followed  by  ^of  Hunyadi  Janos 
water  or  other  saline  purgatives. 

In  severe  cases,  begin  an  opium  influence  at  once,  by  hypodermic  in- 
jections of  morphince  sulphas  guarded  with  atropincB  sulphas,  con- 
tinued until  all  symptoms  of  inflammation  have  subsided,  when 
attempts  to  remove  the  accumulated  fsces  may  be  made  by  irriga- 
tion of  the  bowel  with  warm  soapsuds,  and  the  cautious  administra- 
tion of  magtiesii  sulphas  in  drachm  doses,  every  two  hours. 

Locally,  hot,  dry  applications,  or  the  ice  bag. 


PERITYPHLITIS— APPENDICITIS. 

Synonyms.  Perityphlitic  abscess ;  suppurative  appendicitis ; 
pericaecal  abscess  ;  iliac  abscess. 

Definition.  Perityphlitis  ;  an  acute  inflammation  of  the  connec- 
tive tissue  around  the  caecum  (with  localized  peritonitis)  leading  to 
the  formation  of  an  abscess. 

.  Appendicitis.  An  acute  or  subacute  inflammation  of  the  appendix 
vermiformis,  involving  the  surrounding  tissues  (with  a  localized 
peritonitis),  leading  to  perforation  of  the  appendix  and  the  develop- 
ment of  an  abscess. 

Causes.     The  frequency  with  which  appendicitis  is  met  with  has 
9 


130  rUACTICK    OF    NfEDIClNIi. 

led  to  the  belief  that  the  condition  is  of  germ  origin,  the  exact  nature 
of  which  not  having  been  determined.  The  great  majority  of  cases 
of  perityphlitis  are  secondary  to  inflammation  of  or  perforation  of  the 
vermiform  appendix — appendicitis.  Have  seen  two  cases  of  true 
perityphlitis,  the  result  of  exposure  to  cold  and  wet. 

Appendicitis  may  result  from  the  presence  of  a  foreign  body  in 
its  canal,  consisting  of  inspissated  ficcal  masses,  which,  becoming 
incrusted  with  lime  salts,  are  termed  "  faecal  calculi,"  and  becoming 
rounded  in  shape  closely  resemble  a  cherry-stone,  for  which  they 
have  been  mistaken.  Foreign  bodies,  particularly  seeds  of  fruit, 
sometimes,  but  not  so  often  as  is  believed  by  the  laity,  gain  access 
to  the  appendix  and  produce  inflammation  leading  to  perforation. 
Torsion  of  the  appendix  is  also  among  the  infrequent  causes.  The 
disease  is  more  common  in  males  than  females.  Occurs  most  fre- 
quently between  the  ages  of  ten  years  and  thirty  years.  Relapses 
are  fairly  frequent  in  cases  not  progressing  to  perforation. 

Some  one  has  suggested  the  increased  frequency  of  appendicitis 
since  the  reappearance  of  influenza. 

Symptoms.  The  symptoms  of  the  two  conditions  are  much 
alike;  begins  with  2,  feeling  oi  weight,  soreness,  and  rapidly  develop- 
ing and  severe  pain  in  the  lower  right  abdomen  (McBurney's  point), 
accompanied  with  nausea  and  vomiting.  The  pain  is  increased  by 
lying  on  the  left  side ;  the  right  leg  is  flexed,  the  abdomen  becomes 
tense,  proininent,  and  tender,  with  the  progressive  development  of  a 
hard  swelling  in  the  right  iliac  region.  The  temperature  at  the  onset 
is  from  90°-ioo°,  and  may  or  may  not  be  preceded  by  a  chill;  the 
pulse  80,  full  and  strong ;  the  tongue  coated  with  red  tips,  the  bowels 
costive.  In  addition  to  the  persistent,  localized  pain,  occurs  severe 
colicky  paroxysms,  which  may  shoot  into  the  hip  and  thigh.  The 
expression  of  the  patient  is  pinched  and  denotes  suffering.  The 
special  tendency  of  the  disease  is  toward  suppuration,  which  is  an- 
nounced hy  irregular  c/tills,  fez'erishness,  ihe  temperature  shooting 
suddenly  to  ioi°-io3°,  '^'id  sweats ;  and  a  feeling  of  tension  and 
throbbing.  Its  development  is  slow,  and  if  associated  with  typhlitis 
the  symptoms  of  that  affection  are  added. 

Complications.  Perforationof  the  appendix.  Local  or  general 
peritonitis. 

Diagnosis.  Differs  from  typhlitis  by  the  absence  of  the  colicky 
pains,  dyspeptic  symptoms,  costive  bowels,  and  tympanites  preceding 


DISEASES   OF   THE   INTESTINAL   CANAL.  131 

the  development  of  a  tumor;  in  perityphlitis  the  tumor  is.  present  with 
the  development  of  the  symptoms. 

Psoas  abscess  is  not  associated  with  intestinal  symptoms,  and  the 
discharge  is  free  from  a  faecal  odor.  Renal  and  ovarian  tumors  should 
not  be  sources  of  error.  The  possibility  of  hernial  tumors  must  not 
be  overlooked. 

Treatment.  If  not  associated  with  typhlitis,  the  treatment  is  to 
allay  the  inflammation  in  the  first  stage,  by  either  ice,  locally,  or  freely 
pai}iting  with  tinctura  iodi ;  if  suppuration  is  evident,  surgical  meas- 
ures are  the  indication,  medical  treatment  endangering  life. 


PROCTITIS. 

Synonyms.     Catarrh  of  the  rectum  ;  dysentery  ;  rectitis. 

Definition.  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  rectum  and  anus;  characterized  by  pain,  tenesmus,  and  fre- 
quent stools  of  hardened  faeces,  or  of  mucus,  pus,  and  blood. 

Causes.  Chief  cause,  constipation  ;  also  sitting  on  damp  ground 
or  stone  steps ;  habitual  use  of  enemata  or  purgatives ;  diseases  of 
the  liver;  hemorrhoids. 

Pathological  Anatom.y.  Similar  to  those  occurring  in  catar- 
rhal dysentery. 

Symptoms.  Uneasy  sensation  and  burning  in  the  recfuvi,  with 
a  constant  desire  for  stool,  or  tenesmus,  often  so  severe  as  to  cause  a 
prolapse  of  the  mucous  membra^ie.  The  stools  may  be  either  hard- 
ened fceces  or  scybala  from  the  distended  colon,  which  cause  intense 
pain  when  they  reach  the  rectum  ;  or  the  stools  may  be  of  mucus, 
inucopus,  or  bloody  or  blood-streaked.  Generally  there  are  present 
nausea,  especially  during  the  tenesmus,  headache,  feverishness,  and 
malaise.  In  severe  cases  there  is  strangury,  and,  with  the  tenesmus, 
straining  with  urination. 

If  the  case  be  protracted  and  severe,  inflammation  of  the  connec- 
tive tissue  around  the  rectum  occurs,  causing  periproctitis,  which 
usually  terminates  in  various  kinds  of  fistula. 

Complications.     Periproctitis ;  peritonitis  ;  hepatic  abscesses. 

Diagnosis.  In  males,  the  disease  cannot  be  confounded  with  any 
other  affection,  save,  perhaps,  hemorrhoids.  In  females,  displace- 
ments of  the  uterus  may  somewhat  simulate  the  symptoms  of  proctitis. 


132  PRACTICE   OF    MEDICINE. 

Prognosis.  Uncomplicated  cases  favorable.  Either  of  the  com- 
plications adds  greatly  to  the  gravity  of  the  affection. 

Treatment.  In  cases  due  to  constipation  the  chief  indication  is 
to  empty  the  bowels,  using  an  enema  of  warm  water  and  soap  or 
magnesii  sulphas  : 

IjS. .     Magnesii  siili)h., _^  ij  60.         Gm. 

Glycerin!,    . f.o^s  15.         Cc. 

Aquxbul., fo'^  ^-°-         ^^*  ^^• 

Irrigaiioti  of  the  bowel  with  warm  water  once  or  twice  daily  assists 
in  the  liquefaction  of  the  hardened  faeces.  Either  enemata  or  sup- 
positories oi  glyceriniwt  should  answer  in  certain  cases. 

Cases  other  than  those  due  to  constipation,  emollient  enemata  and 
opiu7n,  one  of  the  best  being — 

li .     01.  olivje, f  3  ij  60.    Cc. 

Tinct.  opii  deodorat., Tt\^xv  i.     Cc. 

The  use  of  hot  injections  of  an  astringent  character,  such  as  hot, 
strong  black  coffee,  from  half  pint  to  quart,  as  hot  as  will  be  tolerated 
by  the  rectum,  as  suggested  by  Dr.  Pepper,  is  valuable  in  cases  of 
irritable  rectum  with  a  disposition  to  looseness.  In  cases  not  bene- 
fited by  the  hot  injections,  relief  may  follow  the  use  of  injections  of 
water,  say  two  ounces,  as  cold  as  can  be  borne  without  chilling, 
administered  at  bedtime,  having  it  retained. 

If  symptoms  oi  periproctitis  occur,  use  ice  to  the  parts,  and  if  sup- 
puration ensue,  evacuation  by  a  free  opening  and  qiiinince  sulphas. 


INTESTINAL  OBSTRUCTION. 

Synonyms.  Intestinal  occlusion;  strangulated  hernia;  invagi- 
nation ;  intestinal  stricture  ;  ileus. 

Definition.  A  sudden  or  gradual  closure  of  the  intestinal  canal; 
characterized  by  pain,  nausea,  vomiting,  constipation,  and  finally  col- 
lapse. 

Causes.     The  numerous  causes  are  arranged  as  follows  : 

1.  Accumulations  within  the  bowel  of  hardened  faeces,  or  foreign 
bodies. 

2.  Strictures  the  result  of  cancer,  ulceration,  or  cicatrices. 

3.  Pressure  against  the  bowel,  from  peritoneal  adhesions,  tumors, 
and  abnormal  growths. 


DISEASES   OF   THE   INTESTINAL   CAXAL.  133 

4.  Strangulations,  due  to  the  numerous  forms  of  hernia. 

5.  Invagination  or  intussusception,  the  most  common. 

6.  Twisting,  volvulus  or  rotation  of  the  bowel. 
Pathological  Anatomy.    Invagination  is  the  form  calling  for 

special  description  here.  It  is  usually  caused  by  the  lower  portion  of 
the  ileum  slipping  down  into  the  caecum,  as  the  finger  of  a  glove 
might  be  invaginated,  causing  thus  an  actual  mechanical  obstruction  ; 
this  is  produced  by  a  spasm  of  the  ileum,  whereby  its  calibre  is  greatly 
diminished,  thus  permitting  its  descent  into  the  lower  bowel.  Result- 
ing from  this  occlusion  or  compression,  are  congestion,  inflammation, 
with  secondary  constitutional  reaction  and  death,  or  more  rarely  the 
invaginated  bowel  sloughs  off  and  is  voided  by  stool,  union  taking 
place  at  its  site  and  recovery  following. 

Symptoms.  The  onset  of  the  symptoms  may  be  either  sudden 
or  gradual,  and  are  as  follows  : 

Constipation,  with  more  or  less  s&vexe  colicky  pains, notr^Yitytdhj 
either  purgatives  or  injections  ;  feeling  of  weight  and  soreftess,  with 
distention  of  the  abdomen  from  retained  gas,  and  nausea  and  vomit- . 
ing ;  the  symptoms  all  grow  more  pronounced,  the  pain  becoming 
violent,  tenderness  in  limited  areas,  the  vo7niting\>&cov!\\Vi^  stercorace- 
ous,  the  abdomen  hard  and  tense,  the  eyes  sunkett,  the  pulse  quick 
z.^^  feeble,  the  skin  cold  and  covered  with  a  clammy  sweat.  Absence 
of  escaping  flatus  is  a  valuable  diagnostic  symptom.  The  above  con- 
tinue more  or  less  pronounced  for  a  week  or  ten  days,  when  collapse 
and  death  occur,  or  more  rarely  there  is  a  gradual  return  to  health. 

Cases  occur  rarely  in  which  small,  f^cal,  muco-purulent  stools  con- 
taining more  or  less  blood  exist,  instead  of  constipation. 

Diagnosis.  One  of  the  most  difficult,  and  can  only  be  solved  by 
a  careful  study  of  the  case  along  with  the  different  causes  producing 
the  affection.  The  sight  of  the  occlusion  can  rarely  be  determined 
positively,  unless  the  X-ray  be  successful. 

Intestinal  obstruction  may  be  mistaken  for  intestinal  colic,  hernia, 
enteritis,  peritonitis,  hepatic  or  renal  colic. 

Prognosis.  Always  grave,  but  guided  by  the  cause.  Impacted 
faces  favorable.  Invagination  less  favorable,  but  recoveries  occur ; 
the  longer  the  symptoms  continue,  the  more  favorable  the  outlook. 
Strangulations  unfavorable,  but  many  recoveries  recorded.  Strictures 
due  to  cancer,  cicatrized  ulcers,  and  the  like,  are  the  most  unfavorable. 

Treatment.  Stop  all  forms  of  purgatives  as  soon  as  the  diagno- 
sis of  obstruction  is  determined. 


134  PRACTICE  OF  mp:dicine. 

opium  is  indicated  in  all  forms  with  pain,  and  is  best  adniinistered 
in  the  form  of  morphina:  sulphas,  combined  with  small  doses  of 
attopina  sulpluis,  hypodermically. 

The  author  has  seen  the  most  brilliant  results  follow  the  plan  of 
washing  out  the  stomach  as  suggested  by  Kiissmaul,  and  with  full 
doses  of  atropines  sulphas  hypodermically,  for  its  action  on  intestinal 
peristalsis,  and  with  electricity,  one  pole  over  abdomen,  the  other  in 
rectum. 

Cases  resulting  from  impacted  fasces  are  rapidly  cured  by  the  above 
plan  combined  with  irrigation  of  the  lower  bowels  with  tepid  soap- 
suds or  a  high  enema  of  glycerinum  and  magnesii  sulphas 

If  invagination,  raising  the  buttocks  and  lowering  the  chest,  and 
repeated  injections  of  warmed  oil,  are  recommended,  or  have  the 
abdomen  opened  and  the  invagination  reduced. 

Distention  of  the  bowel  by  pumping  air  through  long  rectal  tubes, 
or  disengaging  carbonic  acid  gas  in  the  bowel,  by  first  injecting  a  solu- 
tion o{ sodii  bicarbonas,  and  follow  this  with  a  solution  oi  acidum  tar- 
taricum,  about  one  drachm  (4  Gin.)  of  each,  pressure  being  made 
against  the  anus  to  prevent  escape  ;  but  the  danger  of  rupture  of  the 
bowtl  must  not  be  overlooked. 

Flatulent  distention  can  be  removed  by  the  long  aspirator  needle. 

Laparotomy  is  no  doubt  the  operation  of  the  future,  when  our  means 
of  diagnosticating  the  location  of  the  trouble  is  more  exact. 

The  nutrition  of  the  patient  is  best  attained  by  injections  of  either 
peptonized  foods  or  defibrinated  blood,  or  both. 


INTESTINAL  PARASITES. 


TAPEWORMS. 

Varieties.  Tania  solium;  Tcenia  saginata;  Bothriocephalus 
latus. 

Causes.  The  Tania  solium,  the  "  armed  tapeworm,"  is  the  most 
common  in  this  country.  It  is  derived  from  the  embryos  contained 
'\Vi  pork,  known  as  the  cysticercus  cellulosus. 


INTESTINAL   PARASITES.  135 

The  TcBfiia  saginata,  the  "unarmed  tapeworm,"  a  not  uncommon 
variety,  is  derived  from  the  embryos  contained  in  beef,  known  as 
cysticerciis  bovis. 

The  Bothriocephalus  latiis,  also  an  "  unarmed  tapeworm,"  the 
largest  parasite  infesting  man,  is  supposed  to  be  derived  from  an 
embryo  found  mfish. 

The  embryo  or  ovum  is  introduced  into  the  intestinal  canal  with 
the  food  and  drink.  The  parasite  reaches  its  final  growth  after  its 
entrance  into  the  intestines. 

Those  handling  fresh  meats  or  eating  uncooked  animal  food  are 
most  liable  to  be  affected. 

Uncleanliness  is  also  an  important  factor.    " 

Description.  The  tcenia  solium  is  from  six  to  thirty  feet  in 
length,  has  a  globular  head,  or  scolex,  a  slender  neck  connecting  its 
numerous  fiat  segments  or  Joints.  The  head,  or  scolex,  measures 
about  -^-Q  of  an  inch,  has  a  double  circle  of  booklets, — whence  the 
term  "armed  tapeworm," — and  is  provided  with  from  two  to  four 
suckers.  The  segments  or  joints  (strobila)  are  flat,  and  vary  from 
one-eighth  to  one-half  of  an  inch  in  length,  and  each  contains  both 
male  and  female  sexual  organs,  the  uterus  being  a  long,  numerously 
branched  tube,  in  which  the  ova  develop ;  the  ova  measures  about 
YTQo  of  an  inch  in  diameter.  An  ordinary  tapeworm  contains  some 
five  million  ova. 

The  parasite  is  firmly  embedded  in  the  mucous  membrane  of  the 
upper  third  of  the  small  intestines  by  its  booklets  and  suckers. 

The  lower  or  terminal  segments  represent  the  adult  and  complete 
animal,  and  are  termed  the  proglottides,  which  separate  from  the 
parasite  and  are  discharged  either  alone  or  with  the  faeces. 

The  tania  saginata  is  from  ten  to  forty  feet  in  length,  has  a 
rounded  or  oval-shaped  head,  measures  about  ^  of  an  inch,  and 
has  four  strong  and  prominent  suckers,  but  tio  booklets, — whence 
the  term  "  unarmed  tapeworm  "  ;  the  neck  is  short  and  thick  and 
the  segments  are  larger,  stronger,  and  thicker  than  those  of  the  taenia 
solium. 

The  Bothriocephalus  latus  is  the  largest  of  the  three  Cestoda,  the 
length  ranging  from  fifteen  to  sixty  feet,  the  head  oval,  measuring 
about  -^^  of  an  inch,  a  short  neck,  the  segments  or  joints  being  nearly 
three  times  as  broad  as  they  are  long.  Its  color  is  a  dull,  bluish-gray. 
Zoologically  considered,  this  variety  is  not  a  true  tapeworm. 


136  PRACTICE    OF    MEDICINE. 

Syruptoras.  Not  unfrequently  a  tcenia  produces  no  symptoms 
whatever. 

Usually,  however,  there  are  colicky  pains  \.\ixo\xgho\xl  the  abdomen, 
inordinate  appetite,  disorders  of  digestion,  emaciation,  constipation, 
attacks  of  cardiac  palpitation,  faintncss,  disorders  of  the  special 
senses,  und  pruritus  of  the  anus  and  nose.  Any  or  all  of  these  symp- 
toms may  be  present. 

A  large  meal  will  often  remove  the  majority  of  the  symptoms 
present. 

In  a  large  number  of  cases  the  discovery  of  the  sejpnents  is  the  first 
intimation  of  the  presence  of  the  parasite. 

Treatment.  A  number  of  remedies — termed  taeniafuges — are 
used  more  or  less  successfully  for  the  expulsion  of  the  tapeworm. 

The  very  best  of  these  remedies  is  undoubtedly  oleoresince  aspidii, 
foss  (2  Cc),  repeated  or  in  the  following  combination  : 

R .     Oleoresince  aspidii f^ij  8.       Cc. 

Chlorofornii f^ij  8.       Cc. 

Olei  tiglii, TTLiv  .24  Cc. 

Glycerini, f  ~  ij  60.       Cc.  M. 

SiG. — Take  half  at  8  A.  M.  ;  the  rest  in  an  hour  if  needed  (Dock). 

The  other  tsniafuges  often  successful  are  :  e.xtractum  granati  rad. 
cort.  fluidu7n,  f^ss-ij  (2-8  Cc),  or  a  decoctum  granati  rad.  cott. 
(sij — 60  Gm. — bark  of  root,  aquae  Oj — 480  Cc),  wineglassful  every 
hour  until  all  is  taken,  as  suggested  by  Prof.  Bartholow  ;  or  oieum 
pepo  express.,  foj-iv  (4-15  Cc),  followed  by  oleum  ricini. 
Creosotum  has  been  successful  in  a  number  of  cases.  Several  cures 
are  reported  ixom  glyccrinum,  f3ij-f5J  (8-30  Cc),  repeated  p.  r.  n. 

A  much  pleasanter  remedy  is pelietierine,  the  active  constituent  of 
granatum,  used  in  the  form  of  the  tannate,  gr.  .\-x.x  (0.65-1.3  Cm.), 
or  Tanrei's  solution  of  pcllciierine. 

An  important  precaution  in  the  management  is  close  attention  to 
the  "  preparatory  treatment  "  rendered  essential  to  remove  the  mucus 
in  which  the  head {^co\&x)  is  embedded.  It  consists  in  the  adminis- 
tration of  a  thorough  purgative  for  one  or  two  days,  and  a  light  diet, 
such  as  milk  and  broths,  preceding  the  use  of  the  taeniafuge. 


INTESTINAL   PARASITES.  137 

ROUND  WORMS. 

Varieties.     Ascaris  himbricoides  ;  Oxyuris  ver7nicularis. 

Causes.  The  ascaris  lumbricoides  is  one  of  the  most  common  of 
the  parasites  affecting  the  human  family,  and  develops  in  the  intes- 
tines, either  after  the  entrance  of  the  ova  of  the  same,  or  from  the  so- 
called  "  intermediate  parasites."  Their  entrance  is  effected  by  means 
of  the  food  and  drink. 

The  oxyuris  vermicularis  develops  in  the  large  intestines,  from 
either  its  peculiar  ova  or  the  so-called  "  intermediate  parasite,"  these 
finding  their  way  into  the  bowel  with  the  food  and  drink,  or  by  direct 
contact. 

Description.  The  ascaris  lutnbricoides,  or  the  round  woriii,  is  of  a 
brownish  color,  a  cylindrical  body,  from  ten  to  twenty  inches  in  length, 
and  from  an  eighth  to  a  fourth  of  an  inch  in  circumference  ;  the  head 
terminates  in  three  semilunar  lips,  each  having  about  two  hundred 
teeth.  The  ova  are  oval-shaped,  are  produced  in  immense  numbers, 
some  sixty  million  in  a  mature  female,  have  wonderful  vitality,  resist- 
ing extreme  heat  or  cold. 

The  round  w or 7n  inhabits  principally  the  small  intestines,  although 
it  often  migrates  to  other  parts.  They  are  found  in  numbers  from  one 
to  several  hundred. 

The  oxyuris  vermicularis,  thread,  or  seat  worm,  resembles  an  ordi- 
nary piece  of  white  thread,  measuring  from  a  sixth  to  a  half  inch  in 
length,  the  head  terminating  in  a  mouth  with  three  lips,  the  tail  i&r- 
minating  as  a  sharp  point.  The  ova  are  oval,  produced  in  large 
numbers,  each  female  containing  about  ten  thousand,  and  are  sur- 
rounded by  a  stout  envelope,  which  increases  their  vitality. 

The  seat  worm,  as  its  name  indicates,  inhabits  the  large  intestines, 
especially  the  rectum,  although  they  frequently  migrate  to  the  sexual 
organs.  They  vary  in  number,  sometimes  the  parts  frequented  being 
entirely  covered. 

Symptoms.  The  ascaris  li^nbricoides,  or  round  worm,  may  be 
present  in  great  numbers  and  yet  produce  no  characteristic  symptoms 
other  than  gastric  and  intestinal  irritation,  causing  picking  the  nose, 
foul  breath,  colicky  pains,  nausea  and  vomiting,  diarrhoea,  and  dis- 
turbed sleep,  such  as  tossing  from  side  to  side  of  bed  and  grinding 
the  teeth.  Any  or  all  of  these  symptoms  may  be  present  or  absent ; 
a  positive  diagnosis  is  only  possible  upon  the  passage  of  the  parasite. 


138  PRACTICE    01-"    MEDICINE. 

The  oxyuris  vermicularis,  or  seat  worm,  produces  intense  itihing 
about  the  anus,  with  a  desire  for  stool,  the  passages  often  containing 
much  mucus,  the  result  of  the  irritation  produced  by  their  presence. 
Should  they  migrate  to  the  sexual  organs,  intense  itching  of  these 
parts  results,  which,  unless  speedily  corrected,  leads  in  children  to 
masturbation. 

Treatment.  The  ascaris  Itimbricoides  are  readily  removed  by 
the  following  "  worm  powder  "  : 

H  •      S.-intonini, gr.  ^-j-ij  .Ol6-.065-.i3  Cm. 

Ilydrargyri  chlor.  mills,    ....     gr.  j^'-ij      .022-.  13  Cm.  M. 

Ft.  chart. 
SiG. — At  bedtime,  followed  by  a  dose  of  cleutn  ruini  before  breakfast. 

For  the  oxyuris  vermicularis  the  above  santoninuvi  powder,  with 
the  use  oi  enemata  oi  quassia,  aluinen,  sodii  chloridum,  or 

R.     Acidi  carbolic!, gr.  v-x  .3-6        Gm. 

Aquae, Oj  480.  Cc. 

according  to  the  age,  the  injection  not  to  be  retained  ;  or  an  enema  of 
a  weak  solution  of  corrosive  sublimate  (i  to  10,000).  Always  precede 
any  of  the  medicated  enemata  by  a  large  injection  of  water  to  unload 
and  clear  the  rectum.  Washing  the  anus  and  external  genitals  with 
a  solution  of  acidum  carbolicutn  should  also  be  employed.  For  the 
pruritus  ani  apply  a  little  tinguentum  hydrargyri  or  extractum  ham- 
amelis  fluidttm. 


TRICHINOSIS. 

Synonyms.  Trichiniasis;  Trichina;;  Trichina  spiralis;  "flesh- 
worm  disease." 

Definition.  A  typhoid  condition,  the  result  of  the  entrance  of  a 
parasite — the  Trichina  spiralis — into  the  intestinal  canal,  and  their 
subsequent  migration  into  the  muscular  structure;  characterized  by 
severe  gastro-intestinal  irritation,  severe  muscular  soreness,  and  a  low 
typhoid  condition. 

Cause.  The  Trichince  spiralis  are  introduced  into  the  human 
body  by  eating  the  infected  hog's  flesh,  either  raw  or  but  partly  cooked. 

Description.  The  parasite  is  found  in  two  forms,  to  wit:  intes- 
tinal trichina,  which  is  sexually  mature,  and  muscle  trie  hina,v/\\\ch.  is 
sexually  immature. 


INTESTINAL   PARASITES.  139 

The  intestinal  trichina  is  a  small,  hair-like  worm,  the  male  meas- 
uring y\  of  an  inch,  and  the  female  }i  of  an  inch  in  length  ;  the  head 
is  smaller  than  the  rest  of  the  body ;  the  tail  of  the  male  has  a  bi-lobed 
prominence,  between  the  divisions  of  which  the  anal  opening  is  placed, 
and  from  which  a  single  spiculum  can  be  protruded  ;  the  female  has 
a  blunt,  rounded  tail,  the  reproductive  outlet  being  situated  toward 
the  anterior  part  of  the  body ;  the  ova  are  very  small,  containing 
embryos  being  produced  viviparously  at  the  rate  of  at  least  one 
hundred  each  week  after  the  entrance  of  the  female  into  the  intestinal 
canal. 

The  muscle  trichina  develops  its  sexual  apparatus  after  it  has 
entered  the  intestinal -canal  of  the  host. 

The  viable  embryos  discharged  from  the  female  are  in  a  state  of 
motion,  and  at  once  migrate  from  the  intestines  to  the  muscular 
structure  of  the  individual,  and  here  set  up  inflammatory  action, 
they  becoming  surrounded  by  a  capsule  or  shell  in  which  they  are 
coiled. 

After  a  time,  in  the  muscle,  the  trichina  undergoes  a  further  change ; 
lime  salts  being  deposited  in  and  about  the  capsule  and  in  the  para- 
site itself,  when  minute  specks  of  lime  are  seen  distributed  throughout 
the  muscular  structure. 

The  development  of  the  parasite  from  the  period  of  impregnation 
up  to  the  time  of  sexual  maturity  is,  under  favorable  conditions,  less 
than  three  weeks.  Within  two  days  from  the  ingestion  of  the  infected 
pork  occurs  the  maturation  of  the  muscle  larvae ;  in  six  days  more 
the  birth  of  embryos  occur,  and  in  about  two  weeks  the  migrating 
nrogeny  have  arrived  at  their  habitat,  the  muscular  structure. 

Symptoms.  These  depend  upon  the  number  of  parasites  in  the 
infected  food.  According  to  Dr.  Sutton,  of  Indiana,  a  piece  of  pork 
the  size  of  a  cubic  inch  contained  eighty  thousand  trichinee.  There 
are  three  stages  described,  to  wit :  the  intestinal,  the  migration,  and 
the  encapsulation. 

Intestinal  stage,  a  gastro-intestinal  inflammation,  v^\'(hnausea,vom- 
iting,  and  watery  diarrhcea,  the  severity  depending  upon  the  number 
of  the  parasites  ingested. 

Migration  stage,  a  typhoid-like  fever,  rapid,  feeble  pulse,  profuse 
sweats,  intense  thirst,  dry  tongue  and  lips,  and  red,  swollen  face,  with 
soreness  and  tenderness  of  the  muscular  structure,  increased  by  any 
muscular  act.     As  a  rule  the  mind  is  clear  but  decidedly  apathetic. 


140  PRACTICE    OF    MEOICINE. 

Encapsulation  Stage.  If  the  number  of  parasites  ingested  has 
been  few,  recovery  may  occur  in  this  stage  ;  but  if  the  number  has 
been  large,  the  gastro-enleritis,  fever,  and  niuscuhir  phenomena  are 
severe,  the  patient  is  in  a  critical  condition,  between  twenty  and  fifty 
per  cent,  succumbing. 

Diagnosis.  Unless  the  physician  has  some  intimation  of  the 
cause,  cases  are  readily  mistaken  for  either  ordinary  ileo-coliiis  or 
t)  i)hoid  fever. 

Prognosis.  Depends  upon  the  number  of  trichinae  in  the  pork 
eaten.     Mortality  between  twenty  and  fifty  per  cent. 

Treatment.  The  preventive  treatment  consists  in  eating  no  pork 
that  has  not  been  so  prepared  as  to  kill  any  trichina;  that  might  exist. 
If  the  parasites  have  been  recently  taken,  within  the  first  four  or  five 
d2iys,,  emetics  z.r\d. purgatives  or  the  stomach  washed  out  with  intes- 
tinal irrigation  to  remove  them  from  the  stomach  and  intestinal  canal 
are  indicated.  After  thorough  action  from  these,  attempts  may  be 
made  to  destroy  such  of  the  parasites  as  have  escaped  the  action  of 
the  emetic  or  purgative.  For  this  purpose  much  is  said  in  favor  of 
glycerini,  one  part ;  aquce,  two  parts  ;  so  that  one  teaspoonful  (4  Cc.) 
of  glycerinum  be  administered  every  hour  ;  or  a  trial  can  be  made  of 
acidum  carbolicum  and  tinctura  iodi,  as  suggested  by  Prof.  Bartholow. 
QuiniiKx  sulphas  gave  the  best  results  in  the  cases  seen  by  Dr.  Sutton. 

After  migration  has  begun,  the  powers  of  life  should  be  sustained 
by  nourishing  food,  stimulants,  and  tonics,  as  "there  are  no  drugs 
which  have  any  influence  upon  the  embryos  in  their  migration  through 
the  muscles."     (Osier.) 


DISEASES  OF  THE  PERITONEUM. 


PERITONITIS. 

Synonym.     Inflammation  of  the  peritoneum. 

Definition.  A  fibrinous  inflammation  of  the  peritoneum,  either 
acute  or  chronic,  characterized  by  fever,  intense  pain,  tenderness, 
tympanites,   vomiting,   and   prostration.      It  may   be   limited  to  a 


DISEASES   OF  THE   PERITONEUM.  141 

part,  local,  or  it  may  involve  the  entire  membrane,  general,  peri- 
tonitis. 

Causes.  Aaite  variety :  Intense  cold ;  protracted  irritation  by 
blisters  ;  blows  upon  tiie  abdomen  ;  penetrating  wounds  of  the  abdo- 
men ;  inflammation  or  perforation  of  the  stomach,  intestines,  gall  or 
urinary  bladder,  vermiform  appendix,  or  the  surrounding  parts  ;  in- 
flammation of  the  pelvic  viscera  ;  septicaemia  or  pysemia  ;  erysipelas ; 
hernia. 

Many  surgeons  doubt  that  peritonitis  is  ever  an  idiopathic  disease, 
but  that  rarely  it  does  so  occur  is  probable. 

Chronic  variety:  Tuberculosis;  nephritis;  scrofula;  cancer; 
sclerosis  of  the  liver. 

Patholog'ical  Anatomy.  Acute  form  :  hyperasmia  of  the  serous 
membrane,  the  capillaries  distended  and  occasional  extravasations  of 
blood  from  their  rupture ;  the  normal  secretion  is  arrested,  and  the 
shiny  membrane  becomes  dull  and  opaque,  from  an  exudation  of  pure 
fibrin,  which  is  adhesive,  gluing  the  parts  together ;  if  the  inflam- 
matory action  is  now  arrested,  it  is  termed  adhesive  peritonitis ;  if, 
however,  the  action  progress,  an  effusion  of  serous  fluid  is  poured  out 
into  the  peritoneal  cavity,  the  amount  varying  from  a  few  ounces  to 
several  gallons ;  this  is  termed  exudative  peritonitis.  If  recovery 
result,  the  fluid  is  absorbed  with  much  of  the  solid  exudation,  the 
unabsorbed  portions  forming  adhesions  between  the  membrane  and 
the  different  abdominal  organs,  often  causing  great  deformity  and 
irregularity  in  their  relations. 

Local  circumscribed  peritonitis  is  the  same  as  general  except  that 
adhesions  develop  around  the  site  of  attack  so  rapidly  that  the  inflam- 
matory action  is  encapsulated.  Why  this  occurs  in  some  cases  and 
not  in  others  is  not  known.  Pus  develops  if  the  absorption  is  not 
prompt  or  if  any  cachexia  be  present. 

The  chronic  form  follows  the  acute,  or  is  associated  with  tubercu- 
losis, scrofula,  Bright's  disease,  or  sclerosis  of  the  liver. 

The  membrane  is  irregularly  thickened  and  opaque,  with  strong 
adhesions  to  one  or  more  coils  of  the  intestine,  the  liver,  or  spleen ; 
the  quantity  of  fluid  present  is  small,  purulent,  or  sero-purulent  in 
character,  and  encysted  by  the  agglutinated  membrane. 

Symptoms.  Acute  form:  the  onset  is  sudden,  with  a  ^/^z7/,y^z/^r, 
ioi-2)°,  pulse  100-140,  wiry  and  tense,  severe  pain,  cutting  or  boring 
in  character,  and  tenderness,  becoming  so   great  that  the  slightest 


142  PRACTICE    OF    MEDICINE. 

touch  aggravates  it,  the  ihcubiius  being  on  the  back  with  flexed 
thighs;  \\\c  ixbdomcn  is  distendid  and  rt'jp'd,  from  constipalion,  effu- 
sion, and  meteorism  ;  the  diaphragm  is  pushed  up  as  far  as  the  third 
or  fourth  rib  in  severe  cases,  causing  compression  of  the  lungs  and 
displacement  of  the  heart,  liver,  and  spleen.  There  is  ivipaircd  appe- 
tite, intense  thirst,  and  nausea  and  vomiting  are  almost  constant,  as 
is  hiccough.  The  patient  passes  through  the  varioi's  steps  of  the  dis- 
ease rapidly,  collapse  soon  occurring.  It  is  a  clinical  fact  that  a  sub- 
normal temperature  is  of  frequent  occurrence  in  acute  peritonitis. 

Secondary  form,  from  extension,  begins  with  local  and  gradually 
increasing  pain,  the  temperature  increases,  tense  pulse,  and  vomiting. 
If  from  perforation,  it  is  announced  by  severe  pain  and  all  the 
symptoms  of  shock. 

Purulent  peritonitis,  usually  secondary  (most  commonly  seen  in 
those  with  chronic  Bright's  disease),  is  accompanied  with  hectic 
phenomena. 

These  symptoms  continue  from  six  to  eight  days,  when  they  begin 
to  decline  and  a  tedious  convalescence  ensues,  or  pain  and  tender- 
ness grow  more  marked,  strength  fails,  surface  cold,  pulse  rapid,  and 
collapse,  with  hippocratic  face,  anxious  expression,  pinched  features, 
sunken  eyes,  and  drawn  upper  lip. 

Chronic fonn,  usually  of  tubercular  origin,  though  other  causes  are 
given,  shows  irregular  chills,  fever,  and  sweats,  distended  abdomen, 
constipation  alternating  with  diarrhoea,  diffused  tenderness,  with 
points  of  intenseness  2^nd  hardness;  co/icky  pains  during  digestion, 
rapid  emaciation,  and  failure  of  strength.  Usually  the  lower  portions 
of  the  abdomen  give  a  dull  note  on  percussion,  from  the  presence  of 
fluid,  or  scattered  points  of  dullness,  showing  the  presence  of  encysted 
fluid. 

Diagnosis.  The  question  of  diagnosis  in  peritonitis  is  of  great 
importance,  as  it  is  so  frequently,  if  not  always,  associated  with  the 
diseases  and  accidents  of  the  abdomen. 

Acute  gastritis  differs  from  peritonitis  in  having  a  history  of  cor- 
rosive poisoning,  severe  pain,  limited  to  the  stomach,  with  early  and 
severe  vomiting;  while  the  latter  has  fever,  diffused  abdominal  pain 
and  tenderness,  with  decided  distention. 

Acute  enteritis  has  localized  pain  and  tenderness  witli  marked 
diarrhoea;  constipation  being  the  rule  in  peritonitis. 

Rheumatism  of  the  abdominal  muscles  occurs  with  a  rheumatic 


DISEASES   OF   THE   PERITONEUM.  143 

history,  is  subacute,  lacks  the  great  abdominal  distention  and  suffer- 
ing expression  of  peritonitis,  and,  while  tenderness  exists,  it  is  not 
aggravated  by  deeper  pressure. 

Biliary  colic,  or  the  passage  of  a  gall-stone,  has,  as  a  prominent 
symptom,  excruciating  pain,  localized  over  the  common  bile  duct, 
which  is  of  a  paroxysmal  character  and  followed  by  slight  passing 
jaundice.  In  renal  colic  the  acute  pain  follows  the  course  of  the 
ureters,  with  retracted  testicle  and  altered  urinary  secretion. 

Prognosis.  Always  uncertain,  but  if  symptoms  progress  slowly, 
quite  favorable,  as  fatal  cases  usually  end  during  the  first  week. 
Cases  from  perforation  unfavorable. 

Chronic peritotiiiis  being  generally  of  tuberculous  origin,  the  prog- 
nosis is  unfavorable,  although  partial  and  complete  recovery  results  in 
the  cases  following  the  acute  form  of  the  disease. 

Treatment.  The  peritoneal  membrane  being  of  such  vast  extent, 
its  general  inflammation  is  one  of  the  most  formidable  diseases  the 
physician  meets. 

Acute  form  :  Idiopathic  and  robust  cases,  locally,  leeches  or  wet 
cups,  followed  by  cold  or  hot  applications,  as  most  agreeable,  or 
covering  the  abdomen  with  a  blister ;  adynamic  cases,  dry  cups,  fol- 
lowed by  warm  applications  medicated  with  tinctura  opii. 

The  profession  is  divided  between  two  plans  of  treatment  for  peri- 
tonitis, one  side  favoring  opiiun  and  the  other  party  as  strongly  urg- 
ing saline  purgatives  and  laparotomy. 

Prof.  Da  Costa  says  opium  and  quinines  sulphas  are  the  remedies 
indicated  at  the  onset  of  the  disease,  to  wit:  at  once  hypodermic  of 
morphines  sulphas,  gr.  X~/i  (0.016-0.022  Gm.),  maintaining  the  effect 
by  hourly  doses  of  either  morphincB  sttlphas  or  opium,  by  the  mouth. 
Prof.  Clark  ascertained  the  tolerance  of  opium  in  this  disease  by  the 
tremendous  amounts  used  in  a  case  under  his  care ;  the  first  day 
he  gave  200  gr.,  the  second  day  472  gr.,  the  third  day  236  gr.,  fourth 
day  120  gr.,  fifih  day  54  gr.,  sixth  day  22  gr.,  and  on  the  seventh  day 
8  gr.  Prof.  Clark  found  that,  as  a  rule,  however,  morphines  sulphas, 
gr.  Yd-^i  (0.011-0.016  Gm.),  every  two  hours,  would  maintain  the 
effects  of  the  drug.  The  opiiim.  should  be  guarded  with  sufficient 
doses  of  atropines  sulphas.  Quinines  sulphas,  gr.  v  (0.3  Gm.),  every 
four  hours  until  exudation,  after  which  gr.  ij  (0.13  Gm.),  four  times 
a  day,  is  of  marked  benefit. 

While  the  opium  treatment  places  the  patient  a§well  as  the  bowel§ 


144  PRACTICE    OF    MKDICINE. 

"in  splints"  and  relieves  the  pain,  it  is  urged  by  the  advocates  of 
saline  purgatives,  however,  that  instead  of  locking  up  the  bowels,  the 
use  of  salines  puts  the  bowels  into  active  peristaltic  action,  whereby 
the  peritoneal  cavity  is  drained  of  the  products  of  inflammation  and 
the  inflamed  surfaces  are  relieved  of  all  engorgement  by  a  thorough 
depletion  of  the  vessels  in  the  intestinal  walls,  the  pulse  and  temper- 
ature are  improved,  the  pain  is  lessened  as  quickly  as  by  opium,  and 
the  formation  of  adhesions  and  bands  is  prevented. 

Should  the  active  symptoms  continue  under  either  plan  of  treat- 
ment, laparotomy  is  indicated,  and  indeed  there  is  a  growing  opinion 
that  cases  of  peritonitis  should  at  once  be  handed  over  to  the  surgeon. 

The  decline  of  the  vital  powers  must  be  averted  by  regulated  nutri- 
tion and/ree  stimulation. 

Locally,  an  ointment  of  belladonna  and  hydrargyrum  is  of  value. 

During  convalescence,  perfect  quiet,  nourishing  diet,  moderate  stim- 
ulation, scattered  flying  blisters,  and  the  following: 

R.     Potassii  iodidi,        gr- v-x  -S-^      Gm. 

Ferri  pyrophos Rf-  ij  13          tJm- 

Elix.  simpl., f^ss  2.               Cc. 

Aqua;  destillatse, ad  f  3  ij  ad  8.              Cc. 

Every  six  hours. 

should  constitute  the  treatment,  with  tonic  doses  of  quinines  sulphas. 

Peritonitis  from  perforation,  absolute  quiet,  hypodermic  injections 
of  morphincE  sulphas,  ice  locally,  and  stimulants  per  mouth,  rectum, 
or  hypodermically,  and  laparotomy. 

For  puerperal  and  other  varieties  of  peritonitis  following  disease  of 
ovaries,  tubes,  uterus,  and  laparotomy,  the  reader  is  referred  to  works 
on  gynecology  and  surgery. 

Chronic  peritonitis  ;  locally  tinctura  iodi,  and  internally  opium,  for 
pain  ;  potassii  iodidum  as  an  absorbent,  with  nourishing  diet,  oleum 
morrhucB  and  stimulants,  and  rest  in  bed. 


ASCITES. 

Synonyms.  Dropsy  of  the  abdomen  ;  peritoneal  dropsy  ;  hydro- 
peritoneum. 

Definition.  A  collection  of  serous  fluid  in  the  abdomen,  or  more 
correctly  in  the  peritoneal  cavity ;  characterized  by  a  distended  abdo' 


DISEASES   OF   THE   PERITONEUM.  145 

men,  fluctuation,  dullness  on  percussion,  displacement  of  viscera, 
embarrassed  respiration,  ^/z^j  the  symptoms  of  its  cause. 

Causes.  Ascites  may  form  part  of  a  general  dropsy,  to  wit :  car- 
diac or  nephritic.  The  most  common  factor  in  its  production  is  a 
mechanical  obstruction  of  the  portal  system  from  cirrhosis  of  the  liver, 
pressure  of  tumors,  diseases  of  the  heart  or  lungs. 

Pathological  Anatomy.  The  quantity  of  fluid  in  the  perito- 
neal sac  varies  from  a  few  ounces  to  many  gallons.  It  is  generally 
of  a  straw  color,  or  at  times  greenish,  and  is  transparent,  having  an 
alkaline  reaction.  When  blood  is  present  in  any  great  quantity,  it 
points  to  cancer  as  a  cause.  The  peritoneum  becomes  cloudy,  sod- 
den, and  thickened,  from  long  contact  with  the  fluid. 

Symptoins.  The  onset  is  insidious,  and  considerable  swelling  of 
the  abdo7neft  occnrsh&fore.  the  disease  attracts  attention.  Constipa- 
tion, from  pressure  of  the  fluid  on  the  sigmoid  flexure.  Scajiiy 
urine,  from  pressure  on  the  renal  vessels.  Embarrassed  respiration 
and  cardiac  action,  from  displacement  of  the  diaphragm  upward. 
The  umbilicus  is  forced  outward. 

Physical  signs  :  oxv  palpation,  a  peculiar  wave-like  impulse  is  im- 
parted to  the  hand  lying  on  the  side  of  the  abdomen,  while  gently 
tapping  the  opposite  side. 

Percussion  :■  patient  erect,  the  fluid  distends  the  lower  abdominal 
region,  with  dullness  over  the  site  of  the  fluid  and  a  tympanitic  note 
above  ;  if  the  patient  turns  on  his  side,  the  fluid  changes,  and  dullness 
over  the  fluid,  tympanitic  note  over  the  intestines. 

Diagnosis.  Ovarian  tumors  differ  from  ascites  in  the  history,  in 
that  the  enlargement  is  limited  to  the  iliac  fossa,  instead  of  a  uniform 
abdominal  enlargement,  not  changing  its  position  when  the  patient 
changes  posture,  and  by  the  detection  of  a  tumor  by  conjoined 
manipulation  through  vagina,  or  by  rectal  exploration. 

Pregnancy  differs  from  ascites  in  the  character  of  the  enlargement, 
the  history,  absence  of  menses,  increase  of  mammae,  change  in  the 
neck  of  the  uterus,  absence  of  fluctuation,  and  the  presence  of  the 
sounds  of  the  foetal  heart. 

Distention  of  the  bladder  hsiS  been  mistaken  for  ascites  ;  the  points 
of  distinction  are,  in  the  former,  the  history,  presence  of  tenderness 
over  the  bladder,  rounded  outline  of  the  percussion  dullness,  and  the 
relief  afforded  by  the  catheter. 

Chro?iic peritonitis  is  differentiated  by  the  history,  pain,  tenderness, 
10 


146  PRACTICK    OF    MKOICINE. 

more  or  less  vomiting,  thickened  abdominal  walls,  and  its  generally 
being  associated  with  tubercle  or  cancer. 

Chronic  tympanites  presents  the  enlarged  abdomen,  but  lacks  the 
history,  the  dullness,  and  the  fluctuation,  giving  instead  a  tense  abdo- 
men and  a  universal  tympanitic  note. 

Prognosis.  Influenced  by  the  causes  producing  it.  Idiopathic 
ascites,  which  is  most  rare,  terminates  in  health  within  a  few  weeks. 
If  peritonea/,  generally  favorable.  If  from  ori^anic  disease,  most 
unfavorable,  for  while  the  dropsy  may  be  removed,  it  as  rapidly 
returns. 

Treatment.  The  first  indication  is  to  treat  the  cause  of  the  ascites 
and  the  second  to  remove  the  fluid. 

Three  modes  of  removing  the  fluid  present  themselves :  ^rj/,  by 
hydragogue  cathartics ;  second,  diuretics  and  diaphoretics,  and  third, 
tapping.     The  first  and  second  modes  may  be  combined,  as  follows: 

R.      Pulv.  jala])a;  comp., 3J-'j  4.-8.    Gm. 

In  water,  an  hour  before  breakfast; 

And— 

R.     Potassii  acetat., gr.  xxx  2.  Gm. 

Spts.  setlieris  nitrosi T^V  xv  I.  Cc. 

Infus.  digitalis,  .    .    .   q.  s.  ad  f  5  ij  ad     8.  Cc.           M. 
Every  six  hours. 

Or  instead  use  the  following : 

B 

M. 


Hydrargyri  chlor.  mitis,     .    .    .    gr.  iij 

Ext.  opii, gr.  ^V 

Ft.  pil. 

.2      Gm 

.005  Gm. 

Sic. — One  every  three  or  four  hours. 

If  these  fail,  as  they  certainly  will  after  a  time,  the  embarrassed 
respiration  and  cardiac  action  will  call  for  tapping,  which  may  be 
done  with  the  trocar  or  the  aspirator.  The  tapping  does  not  remove 
the  cause,  and  the  fluid  often  rapidly  accumulates  again.  Before 
tapping  always  examine  the  bladder,  using  the  catheter  if  there  be 
any  doubt. 

As  all  modes  of  treatment  weaken  the  patient,  the  diet  should  be 
highly  nutritious,  and  the  system  supported  with  strychnincB  sulphas. 


DISEASES   OF  THE   BILIARY   PASSAGES.  147 


DISEASES  OF  THE  BILIARY  PASSAGES. 


CATARRHAL  JAUNDICE. 

Synonyms.     Catarrh  of  the  bile  ducts  ;  icterus. 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  bile  ducts  and  of  the  duodenum  ;  characterized  by 
gastro-intestinal  derangement,  yellowness  of  the  skin  and  sclera, 
itching  of  the  skin,  feverishness,  and  mental  depression. 

Causes.  Excesses  in  eating  and  drinking;  a  debauch  ;  malaria; 
climatic,  as  cool  nights  succeeding  warm  days. 

Pathological  Anatomy.  The  mucous  membrane  of  one  or 
more  of  the  bile  ducts,  or  of  the  duodenum,  becomes  hyperasmic, 
swollen,  and  thickened,  from  an  effusion  of  serum  into  the  submucous 
tissue ;  the  result  of  this  condition  is  the  closure  of  the  biliary  pas- 
sages, thereby  impeding  the  outward  flow  of  bile.  The  bile  in  the 
hepatic  ducts  being  retained  by  the  obstruction,  the  result  is  a  stain- 
ing of  the  liver  substance  and  an  absorption  of  bile,  and  its  appear- 
ance in  the  blood. 

Symptoms.  Begins  by  epigastric  distress,  coated  tongue,  im- 
paired appetite,  nausea,  with  perhaps  vomiting,  and  looseness  of  the 
bowels  and  slight  feverishness,  the  phenomena  of  a  gastro-intestinal 
catarrh.  In  from  three  to  five  days  the  eyes  becotne yellow  and  jat/n- 
dice  gradually  appears  over  the  whole  body  ;  the  feverishness  disap- 
pears, the  skin  becomes  harsh,  dry,  and  itchy,  the  bowels  constipated, 
the  stools  whitish  or  clay-colored,  accompanied  with  muchy?a/z«,  and 
colicky  pains  ;  the  uritie  heavy  and  dark,  loaded  with  urates  and  con- 
taining biliary  elements. 

A  few  drops  of  the  urine  placed  on  a  whitish  surface,  and  a  drop  or 
two  of  nitric  acid  made  to  flow  against  it,  will  exhibit  the  following 
"play  of  colors"  :  a  greenish  tint,  from  the  conversion  of  bilirubin 
into  biliverdin,  quickly  followed  by  bhie,  violet,  red,  and  yellow,  or 
brown. 

When  XhQ  Jaundice  is  complete,  the  surface  is  cold,  the  heart" s  action 
slow,  the  mind  torpid  and  greatly  depressed,  and  pain  or  tenderness 
on  pressure  over  the  hepatic  region. 


148  PRACTICE    OF    MEDICINE. 

Duration.  In  from  three  to  five  days  after  the  jaundice  appears 
the  symptoms  subside,  save  the  torpid  bowels,  depression,  and  discol- 
ored skin,  which  slowly  disappear,  often  requiring  a  week  or  two. 

Diagnosis.  There  are  two  varieties  of  jaundice,  and  in  arriving 
at  a  diagnosis  this  must  be  remembered.  There  is  hepatogenous, 
obstructive  or  catarrhal  jaundice,  and  hematogenous,  non-obstructive 
or  blood-change  jaundice. 

The  numerous  diseases  of  which  jaundice  is  a  symptom  will  be 
differentiated  when  treating  of  them. 

Prognosis.  Catarrhal  jaundice  always  favorable;  if  the  attacks 
are  of  frequent  occurrence,  however,  they  are  apt  to  lead  to  organic 
hepatic  changes.  If  jaundice  shows  tendency  to  linger,  it  is  probably 
result  of  organic  condition.  • 

Treatment.  Rest  in  bed,  with  a  carefully  regulated  diet,  avoiding 
all  starchy,  fatty,  or  saccharine  articles,  milk  being  the  most  suitable, 
adding  lime-water  if  the  stomach  be  irritable. 

The  jaundice  being  the  result  of  an  acute  catarrh  of  the  duodenum 
and  the  ductus  choledochus  communis,  treatment  is  to  be  directed  to 
this  condition  by  such  remedies  as  sodii  phosphas,  3j  (4  Gm.),  well 
diluted,  every  four  hours,  or  calomel  and  soda  (R .  Hydrargyri  chloridi 
mitis,  gr.  %  (0.016  Gm.);  sodii  bicarbonatis,  gr.  iij  (0.2  Gm.)  ;  sacc. 
lac,  gr.  iij  (0.2  Gm.) ;  M.  SiG. — Taken  dry  on  tongue  every  two  or 
three  hours  until  one  dozen  are  used,  followed  by  Hunyadi  Janos 
water),  or  the  following  : 

fit.     Sodii  bicarb., ^:^iv  15.  Gm. 

Tinct.  nucis  vom., f  .o  iv  15-  Cc. 

Tinct.  capsici, f^j  4.  Cc. 

Tinct.  rhei, f,^ij  60.  Cc. 

Inf.  gent,  comp.,    .    .    .    q.  s.  ad  f5vj  ad  180.  Cc. 

SiG. — Dessertspoonful  every  four  or  five  hours,  in  water. 

For  the  dry,  itchy  skin  diaphoresis  is  indicated.  The  warm  or  hot 
bath  night  and  morning  is  valuable,  adding  potassii  carbonas,  5J  (30 
Gm.)  to  each.  A  weak  carbolic  solution  often  relieves  a  troublesome 
itching,  2LndJ)otassii bromidi,  gr.  xxx  (2  Gm.),  overcomes  the  insomnia 
and  restlessness  of  itching. 

If  the  urine  continues  scanty,  diuretics shouXd  be  used,  a  simple  and 
efficacious  one  being  potassii  bitartras  lemonade  at  very  frequent 
intervals.  Spiritus  cetheris  nitrosi,  tt\,x-xx  (0.6-1.3  Cc),  diluted,  is 
always  valuable  for  torpid  kidneys. 


DISEASES   OF  THE   BILIARY   PASSAGES.  149 

If  under  the  above  plans  of  medication  the  constipation  continues, 
a  pill  of  aloes  and  podophyllum  may  be  useful. 

A  special  plan,  which  is  said  to  be  effective,  is  with  "  enemata  of 
cold  water.  By  means  of  an  irrigating  apparatus  the  large  intestine 
is  well  distended  with  water  once  a  day  for  several  days.  The  first 
enema  has  a  temperature  of  60°  F.,  and  subsequent  injections  are  a 
little  warmer.  The  increased  peristalsis  of  the  bowels  and  the  reflex 
contractions  of  the  gall-bladder  dislodges  the  mucus  obstructing 
the  gall  ducts.  When  the  bile  flows  into  the  intestine,  digestion  is 
resumed  and  the  catarrhal  inflammation  subsides,"  Other  remedies 
may  be  conjoined  with  the  irrigation  method. 

For  convalescence  : 

R.     Strychninaa  sulph. , gr-  ss  .03  Gm. 

Acid,  nitrohydrochloric.  dil.,  .    .  fjiv  15.       Cc. 

Tinct.  gentian,  comp., f^iiss  75.       Cc. 

SiG. — Teaspoonful  after  meals,  well  diluted. 


BILIARY  CALCULI. 

Synonyms.     Hepatic  calculi ;  gall-stones  ;  hepatic  colic. 

Definition.  Concretions  originating  in  the  gall-bladder,  or  biliary 
ducts,  derived  partly  or  entirely  from  the  constituents  of  the  bile. 
Their  presence  is  generally  unrecognized  until  one  or  more  attempt 
to  pass  along  the  ducts,  when  an  attack  oi  hepatic  colic  is  produced. 

Causes.  Gall-stones  result  from  the  precipitation  of  the  crystal- 
lizable  cholesterine,  and  its  combination  with  inspissated  mucus  in  the 
gall-bladder  or  ducts. 

A  disease  of  middle  life,  and  more  frequent  in  the  obese,  and  in 
women. 

Gall-stones  are  said  to  be  common  in  carcinoma  of  the  stomach  or 
liver. 

Pathological  Anatomy.  Cholesterine  is  the  chief  constituent 
of  biliary  calculi.  Commonly  several  stones  exist,  and  rarely  one  ; 
as  many  as  six  hundred  are  recorded.  They  are  generally  found  in 
the  gall-bladder  or  cystic  duct,  rarely  in  the  liver  or  hepatic  duct. 

Symptoms.  The  presence  of  gall-stones  or  biliary  calculi  is 
made  known  only  by  their  expulsion  from  the  gall-bladder,  whence 
is  developed  hepatic  colic. 


150  PRACTICK    OF    MEDICINE. 

Hepatic  colic  begins  suddenly,  at  the  moment  a  gall-stone  passes 
from  the  gall-bladder  into  the  cystic  duct. 

The  patient  is  seized  with  a  piercing,  agonizing  pain  in  the  region 
of  the  gall-bladder,  and  spreading  over  the  abdomen,  right  chest  and 
slioulder;  tlie  abdominal  muscles  are  cramped  Sirxdi  tender ;  there  are 
nausea  and  7>oiniiing,  a.  smM,/eedle  pulse,  cool  skin,  pale,  distorted, 
anxious  face,  with,  may  be,  fainting,  spasmodic  trembling,  chills,  or 
convulsions. 

The  paroxysm  continues  from  an  hour  or  two  to  several  days,  with 
remissions,  but  entire  relief  is  not  afforded  until  the  stone  reaches  the 
duodenum,  when  the  pain  suddenly  ceases. 

Jaundice  usually  follows  the  paroxysm  of  pain.  When  the  calculi 
reaches  the  intestines,  the  pain,  nausea,  and  vomiting  cease,  the  appe- 
tite returns,  and  the  jaundice  soon  disappears. 

Should  the  calculi  become  impacted,  ulcerative  perforation  and 
consequent /<frz/<5«z//j  follow,  the  calculi  discharging  by  the  intestine, 
stomach,  or  through  the  abdominal  walls. 

Diagnosis.  The  malady  should  not  be  mistaken  if  severe  pain, 
diverging  from  the  hepatic  region,  and  nausea  and  vomiting  are 
present,  suddenly  terminating,  and  followed  by  ^\\^\.  jatoidice.  The 
diagnosis  is  always  made  positive  by  diluting  the  stools  voided  for  the 
day  following  an  attack  of  suspected  hepatic  colic,  and  passing  them 
through  a  sieve,  when  the  stone  will  be  secured  if  present. 

Prognosis.  Usual  termination  is  in  health.  The  prognosis  be- 
coming more  unfavorable  if  ulcerative  perforation  result. 

Treatment.  For  the  colic,  hypodermic  injections  of  morp/iince 
sulphas,  gr.  Y^-yi-yi  (o.oi  1-0.022-0.3  Gm.),  combined  with  atropines 
sulphas,  gr.  ^V  (o.ooi  Gm.),  and  warm  fomentations  over  the  hepatic 
region,  are  indicated.  Oleum  olives  puree,  f^ij-iv  (60-120  Cc),  every 
hour  or  two,  sometimes  does  good. 

Prof.  Bartholow  strongly  urges  the  following  prophylactic  treat- 
ment: Carefully  regulated  diet,  abstinence  from  all  fatty  and  sac- 
charine substance,  daily  exercise,  stoppage  of  all  excesses,  and  the 
long  use  of  sodii  phosphas,  3j  (4  Gm.),  before  meals,  well  diluted, 
to  which  may  be  added,  if  gastro-intestinal  catarrh  be  present,  sodii 
arsenias,  gr.  -^^  (0.003  Gm.),  or  aurii  et  sodii  chloridum,  gr.  -^  (0.003 
Gm.),  together  with  either  Vichy  or  Saratoga  Vichy  water. 


DISEASES   OF  THE   LIVER.  151 


DISEASES  OF  THE  LIVER. 


CONGESTION  OF  THE  LIVER. 

Synonyms.     Torpid  liver ;  biliousness. 

Definition.  An  abnormal  fullness  of  the  vessels  of  the  liver, 
with  consequent  enlargement  of  that  organ ;  it  is  terined  active 
when  arterial ;  passive  when  venous.  The  condition  is  characterized 
by  torpidity  of  the  digestive  and  mental  functions,  and  slight  jaun- 
dice. 

Causes.  Active  congestioti ;  heat,  atmospherical  or  artificial ; 
habitual  constipation  ;  malaria ;  excesses  in  eating  and  drinking ; 
alcoholic  or  malt  liquors.  In  females,  an  arrested  menstrual  epoch 
may  give  rise  to  an  attack. 

Passive  congestion ;  cardiac  and  pulmonary  diseases. 

Pathological  Anatomy.  The  liver  is  enlarged  in  all  direc- 
tions, and  is  abnormally  full  of  blood.  Cases  due  to  obstructive 
diseases  of  the  heart  or  lungs  present  the  so-called  "  nutmeg  liver," 
to  wit:  "At  the  centre  of  each  lobule  the  dilated  radicle  of  the 
hepatic  vein,  enlarged  and  congested,  may  be  discerned,  while  the 
neighboring  parts  of  the  lobule  are  pale,"  the  radicles  of  the  portal 
vein  containing  less  blood. 

Long-continued  congestion  establishes  atrophic  degeneration  of  the 
organ  ;  the  decrease  in  size  is  confounded  with  the  condition  of  cir- 
rhosis, but  the  "  atrophic  liver  "  is  smooth,  while  the  "  cirrhotic  liver  " 
is  nodulated. 

Symptoms.  Active  congestion ;  following  cause,  rapidly  pro- 
duced malaise,  aching  of  limbs,  evening  feverishness,  headache, 
depression  of  s.'givaX.'s,, yellowish  tongue,  disgust  for  food,  nausea,  and, 
may  be  vofniting,  constipation,  .scanty,  high-colored  urine,  with  a 
feeling  oi  fullness,  weight,  and  soreness  in  the  hepatic  region,  with 
dull  pain  extending  to  the  right  shoulder,  and  z\v^\.  jatmdice,\h.Q.  eye 
yellow,  and  the  complexion  tnuddy.     Duration  about  a  week. 

Passive  congestion ;  onset  gradual,  with  a  feeling  of  weight  and 
fullness  in  the  hepatic  region,  slight  jaundice,  and  symptoms  of  gas- 
tro-intestinal  catarrh. 


152  PRACTICE    OF    MEDICINE. 

On  pi'trussion  the  hepatic  dullness  is  increased  in  all  directions. 

Diagnosis.  Acute  congestion  is  continually  confounded  with 
catarrhal  jaundice  :  the  latter  begins  with  marked  gastro-intestinal 
symptoms  and  distinct  jaundice ;  in  the  former  these  are  less 
marked. 

Obstructive  congestion  is  diagnosticated  by  the  clinical  history. 

Atrophic  or  nutmeg  liver  will  be  differentiated  from  cirrhotic  liver 
when  speaking  of  the  latter. 

Prognosis.  Active  congestion  favorable,  unless  repeated  attacks 
occur,  rapidly  succeeding  each  other,  when  "  atrophic  degeneration  " 
results. 

J assive  congestion  controlled  entirely  by  the  cause. 

Treatment.     Attacks  due  to  excess  in  eating  and  drinking — 

B.     Sodii  bicarb. , gr.  v  .3  Gm. 

Pulv.  ipecac, gr.  ss  .03        Gm. 

Hydrargyri  chloridi  mit.,        .    .    .    gr.  iij-v  •2-.3    Gm. 

repeated,  followed   by  saline,  or  sodii  phosphas,  3j  \4  Gm.),  every 
four  hours  until  free  catharsis,  or  followed  by 

R.     Acid,  nitrohydrochloric.  dil.,  .    .    Tr\^x  .6  Cc. 

Elix.  taraxaci  comp., f  3  ij  8.    Cc. 

Before  meals. 

Attacks  due  to  malaria  ;  the  above  purgatives,  followed  by  quinines 
sulph.,  gr.  iv  (0.26  Gm.),  every  four  hours. 

Attacks  occurring  with  cardiac  or  pulmonary  diseases  must  be 
managed  by  treating  the  cause. 

The  tendency  to  constipation  must  be  overcome  by  the  saline  laxa- 
tive waters,  to  wit:  Congress  or  Hathorn,  Hunyadi  Janos,  or  sodii 
phosphas,  5j-ij  (4-8  Gm.)  three  or  four  times  daily,  well  diluted. 

Locally,  in  acute  attacks,  hot  cloths  or  sinapisms  are  of  benefit. 

In  chronic  cases  benefit  follows  the  long  use  of  strychtiina:  arseniat. 
or  sodii  arseniat.,  and  great  comfort  and  support  is  given  by  the  use 
of  the  "hydropathic  belt,"  which  is  made  of  stout  muslin,  shaped  to 
the  abdomen,  with  cross-pieces  of  tape  on  the  inner  side,  which  keeps 
next  to  the  skin  a  fold  of  cloth  wrung  out  of  cold  water,  and  a  piece 
of  waterproof  cloth  or  oiled  silk,  to  prevent  evaporation. 

In  persons  who  seem  to  have  a  predisposition  to  attacks  of  conges- 
tion of  the  liver  upon  the  slightest  exposure  to  any  of  the  various 


DISEASES   OF   THE   LIVER.  153 

exciting  causes,  the  habits  and  diet  must  be  regulated,  adding  a 
course  of  alkahne  waters  and  regulated  exercise. 


ABSCESS  OF  THE  LIVER. 

Synonyms.  Parenchymatous  hepatitis ;  acute  hepatitis ;  sup- 
purative hepatitis. 

Definition.  A  diffused  or  circumscribed  inflammation  of  the 
hepatic  cells,  resulting  in  suppuration,  the  abscesses  being  sometimes 
single,  at  times  double;  characterized  by  irregular  febrile  attacks, 
hepatic  tenderness,  and  symptoms  of  deranged  gastro-intestinal  and 
hepatic  functions. 

Causes.  The  result  of  the  absorption  of  putrid  material  by  the 
portal  radicles  in  dysentery  ;  ulcers  of  the  stomach  ;  malaria  ;  blows 
and  injuries  ;  heat ;  associated  with  or  following  pyemic  abscess. 

Pathological  Anatomy.  If  the  result  of  inflammation,  usually 
have  one  large  abscess ;  if  secondary  to  pysemic  conditions,  have  a 
number  of  small  abscesses  (multiple  abscess).  Usually  found  on 
right  lobe.  Hypersemia,  swelling,  effusion  of  lymph,  degeneration 
and  softening  of  the  hepatic  cells  ;  suppuration,  beginning  in  points 
in  the  lobules  and  coalescing.  The  abscess  walls  consist  of  the  liver 
structure,  more  or  less  changed. 

The  abscess  may  advance  toward  the  surface  of  the  liver,  bursting 
into  the  peritoneum,  intestines,  stomach,  gall-bladder,  hepatic  duct 
or  vein,  or  into  the  pleura  or  lungs,  or  externally  through  the 
abdominal  walls  ;  after  the  discharge  of  pus,  cicatrization  occurs, 
or  the  pus  may  be  absorbed,  the  tissues  around  forming  a  dense 
cicatrix. 

Symptoms.  Very  obscure.  Fever  simulating  markedly  inter- 
mittent or  remittent  fevers;  disorders  of  the  gastrointestinal  canal 
with  obstinate  vomiting,  debility ,  and  great  irritability  of  the  nervous 
system,  melancholia,  slight  jautidice,  coitstipatiott,  the  stools  light  col- 
ored, and  if  of  long  duration,  typhoid  symptoms. 

Locally,  if  the  abscess  is  near  the  sMxis-ce,  prominence  of  the  hepatic 
region,  throbbing,  limited  tenderness,  and  if  the  abscess  tends  to  the 
surface,  redness,  oedema,  and  fluctuation.  The  abscess  may  burst 
into  the  intestines,  stomach,  lungs,  or  pleura,  the  symptoms  of  which 
conditions  will  be  pronounced. 


154  PRACTICE    OF    MEDICINE. 

Diagnosis.  Hepatic  abscess  may  be  confounded  with  hydatids 
of  the  liver,  hepatic  or  gastric  cancer,  abscess  of  the  abdominal  walls, 
and  purulent  effusion  in  the  right  pleural  cavity. 

The  differentiation  is  most  difficult,  hui  ^reat  aid  is  obtained  from 
the  use  of  the  aspirator. 

Prognosis.  Unfavorable.  Recoveries,  however,  do  occur.  H 
the  abscess  bursts  into  the  lungs,  bowels,  or  externally  through  the 
abdominal  wall,  the  case  is  more  favorable. 

Treatment.  Sy7ttptomatic,  and  when  pus  is  present,  the  use  of 
the  aspirator  \.o  remove  it,  and  sustaining  treatment,  qvinitice  sulphas, 
ferrum,  alcohol,  and  oleum  morrhua. 


ACUTE  YELLOW  ATROPHY. 

Synonyms.  General  parenchymatous  hepatitis ;  malignant  jaun- 
dice ;  hemorrhagic  icterus. 

Definition.  An  acute,  diffused,  or  general  inflammation  of  the 
hepatic  cells,  resulting  in  their  complete  disintegration  ;  characterized 
by  diminution  in  the  size  of  the  liver,  deep  jaundice,  and  profound 
disturbance  of  the  nervous  system;  terminating  in  death,  usually, 
within  one  week. 

Causes.  Unsettled.  It  occurs  frequently  (?)  in  young  pregnant 
women,  from  the  third  to  the  sixth  month  of  pregnancy.  Other 
causes  are  venereal  excesses,  syphilis,  action  of  phosphorus,  arsenic, 
or  antimony. 

Pathological  Anatomy.  Begins  with  hyperemia  of  the 
hepatic  cells,  with  a  grayish  exudation  between  the  lobules,  followed 
by  softening,  dull  yellow  color,  and  disappearance  of  the  cells,  fat 
globules  taking  their  place;  the  liver  is  reduced  in  size  and  weight ; 
the  peritoneum  covering  the  liver  is  thrown  into  folds  ;  the  spleen  is 
enlarged;  the  kidneys  undergo  degeneration;  the  blood  contains  a 
large  amount  of  urea  and  considerable  leucin ;  the  urine  is  loaded 
with  bile  pigment,  and  contains  albumin. 

Symptoms.  Prodromic  period :  begins  as  a  gastro-intestinal 
catarrh,  coated  tongue,  nausea,  vomiting,  tenderness  over  the  epigas- 
trium, headache,  quickened  pulse,  slight  fever  and  ■s,\\^\.  jautidice . 

Icteric  period :  jaundice  deepens,  pulse  slow,  headache  increases, 
and  persistent  ijisomnia. 


DISEASES   OF  THE  LIVER,  155 

Toxcemic period :  fever,  rapid ///Ai?,  more  com^plete jaundice,  pain, 
nausea,  vomiting  of  blackish  gnanous  blood,  or  "  coffee  grounds," 
tarry  stools,  ecchymotic  patches,  convulsions  or  epileptiform  attacks, 
coma,  insensibility,  death. 

Percussion  shows  markedly  decreased  hepatic  dullness. 

Duration.     Short.    After  appearance  of  jaundice,  about  six  days. 

Prognosis.     Unfavorable. 

Treatment.  Entirely  symptomatic.  Prof.  Bartholow  "advises 
the  trial  of  very  small  doses  of  phosphorus,  as  early  as  possible,  as 
this  remedy  affects  the  organ  specifically,  and  an  action  of  antagon- 
ism may  be  discovered  between  them." 


SCLEROSIS  OF   THE  LIVER. 

Synonyms.  Interstitial  hepatitis ;  cirrhosis  of  the  liver ;  hob- 
nailed liver  ;  gin-drinkers'  liver. 

Definition.  An  inflammation  of  the  intervening  connective 
tissue  of  the  liver,  chronic  in  its  progress,  resulting  in  an  induration 
or  hardening  of  the  organ,  and  an  atrophy  of  the  secreting  cells ; 
characterized  by  gastro-intestinal  catarrh,  emaciation,  slight  jaundice, 
and  ascites. 

Causes.  The  prolonged  use  of  alcoholic  stimulants,  gin,  whisky, 
beer,  or  porter';  syphilis.  I  have  seen  two  cases  in  persons  suffering 
with  uric  acid  diathesis  who  were  not  alcoholics. 

Pathological  Anatomy.  First  stage  :  hyperaemia  of  the  con- 
nective tissue  (Glisson's  capsule)  of  the  liver,  and  the  development 
of  brownish-red  connective-tissue  elements,  whereby  the  organ  is 
increased  in  size  and  density ;  this  increase  of  the  connective  tissue 
presses  upon  the  hepatic  cells,  causing  them  to  undergo  fatty  degen- 
eration. 

Second  stage  :  the  newly  formed,  imperfectly  developed  connective 
tissue  contracts,  causing  decrease  in  the  size  and  induration  of  the 
organ,  its  surface  being  nodulated.  The  hepatic  and  portal  circula- 
tion is  obstructed,  from  obliteration  of  their  radicles. 

The  hepatic  peritoneum  is  thickened  and  opaque,  and  adhesions 
are  formed  to  the  diaphragm,  gall-bladder,  and  stomach. 

The  changes  in  the  hepatic  structure  interfere  with  the  venous  cir- 
culation of  all  the  abdominal  organs,  with  the  consequent  venous  con- 


156  PRACTICE    OF    MKDICINE. 

gestion  of  the  stomach,  spleen,  pancreas,  intestines,  and  peritoneum, 
and  enlargement  of  the  abdominal  veins. 

Cases  occur  in  which  the  sclerosis  takes  place  while  the  organ 
continues  enlarged  ;  these  cases  are  known  as  hypertrophic  sclerosis. 
But  whether  the  liver  be  diminished  or  increased  in  size,  both  are 
the  result  of  an  abnormal  development  of  connective  tissue,  in  one 
case  contraction  being  a  prominent  feature,  and  in  the  other  not 
so. 

Symptoms.  No  characteristic  symptoms  of  the  early  stage  of 
the  affection.  Persistent  gastrointestinal  catarrh,  with  attacks  of 
jaundice,  in  a  drinking  man,  are  suspicious.  Symptoms  of  the  second 
s\.dL.gesa.Teabdo}ninal  dropsy,  enlargement  of  the  superficial  abdominal 
veins,  dyspepsia,  localized  peritoneal  pain,  hemorrhages  fiom  the 
stomach  ox  intestines,  muddy  or  ^\\^^\y  jaundiced  skin  and  decided 
emaciation;  the  enormously  distended  abdomen  with  thin  legs  are 
characteristic  of  sclerosis  of  the  liver. 

I  have  seen  two  cases  in  which  the  condition  was  unsuspected 
until  the  development  of  a  gradually  increasing  and  persistent  epis- 
taxis,  which  continued  until  death,  within  a  month  of  the  onset,  the 
liver  being  far  advanced  in  sclerosis  without  any  rational  symptoms. 

Diagnosis.  Atrophy  of  the  liver,  or  the  nutmeg  liver,  is  almost 
always  confounded  with  sclerosis  ;  the  former  occurs  most  commonly 
with  obstructive  diseases  of  the  heart  and  lungs,  and  the  surface  of 
the  organ  is  not  nodulated,  nor  is  there  a  history  of  alcoholism. 

Cancer  and  tubercle  of  the  peritoneum  have  many  symptoms  akin 
to  sclerosis.  The  points  of  differentiation  are,  great  tenderness  over 
abdomen,  rapidly  developed  ascites,  rapid  decline  in  strength  and 
flesh,  absence  of  jaundice,  absence  of  long-continued  dyspepsia,  ab- 
sence of  hepatic  changes  on  percussion,  and  the  presence  of  tubercle 
or  cancer  deposits  in  other  organs. 

Prognosis.  Terminates  in  death.  Average  duration  after  ap- 
pearance of  the  dropsy,  one  year. 

Treatment.  For  the  changes  in  the  hepatic  structures,  little,  if 
anything,  can  be  done;  the  following  are  some  of  the  remedies  rec- 
ommended, to  wit :  hydrargyri  chloridumcorrosivum,  gr.  ^^—52  (0.00 1 - 
o  002  Gm.),  three  times  a  day ;  hydrargyri  chloridum  mite,  gr.  ^^ 
(0.00065  Gm.),  three  times  a  day ;  aurii  et  sodii  chloridum,  gr.  ^\j 
(0.003  Gm.),  after  meals  ;  sodii  phosphas,  3ss-j  (2-4  Gm.),  after 
meals  ;  potassii  iodidum,  after  meals. 


DISEASES   OF   THE   LIVER.  157 

The  diet  must  be  regulated,  milk  being  the  most  suitable,  and 
particularly  avoiding  fatty  and  saccharine  foods. 

The  abdominal  dropsy  maybe  temporarily  benefited  \>y  purgatives 
and  diuretics,  but  sooner  or  later  tapping  becomes  necessary. 


AMYLOID  LIVER. 

Synonyms.  Waxy  liver ;  lardaceous  liver ;  scrofulous  liver ; 
albuminous  liver. 

Definition.  A  peculiar  infiltration  into,  or  a  degeneration  of,  the 
structure  of  the  liver,  from  the  deposit  of  an  albuminoid  material 
which  has  been  termed  amyloid,  from  a  superficial  resemblance  to 
starch  granules. 

Causes.  The  chief  cause  is  prolonged  suppuration,  especially  of 
the  bones ;  coxalgia;  syphilis;  cancer. 

Pathological  Anatomy.  The  liver  is  uniformly  enlarged.  It 
presents  a  pale,  glistening,  translucent  appearance,  and  has  a  doughy 
consistency.  On  section,  the  surface  is  homogeneous,  is  ansemic  and 
whitish.  The  deposit  begins  in  the  arterioles  and  capillaries,  finally 
closing  them. 

The  reaction  with  iodine  and  sulphuric  acid  affords  a  certain  test 
of  the  amyloid  or  albuminoid  deposits.  After  further  cleansing,  brush 
over  the  parts  a  solution  of  iodine  with  iodide  of  potassium  in  water, 
when  they  will  assume  a  mahogany  color,  and  if  diluted  sulphuric 
acid  be  added,  a  violet  or  bluish  tint  is  produced. 

A  pretty  reaction  is  to  take  a  one  per  cent,  solution  of  aniline  violet, 
which  strikes  a  red  or  pink  color  with  the  amyloid  or  albuminoid 
material,  while  the  unaltered  tissues  are  stained  blue,  thus  showing  a 
beautiful  contrast. 

The  amyloid  change  involves  the  spleen,  kidney,  intestines,  and 
other  organs. 

Symptoms.  Nothing  characteristic.  Hepatic  dullness  increased, 
with  prominence  over  the  liver ;  absence  of  pain  ;  splenic  dullness 
increased  ;  emaciation  and  anEemia  ;  urine  increased  in  amount,  pale 
and  containing  some  albumin,  due  to  amyloid  changes  in  the  kidneys. 
Disorders  of  digestion,  with  diarrhoea,  due  to  amyloid  changes  in  the 
intestines.    Jaundice  is  rare.     Ascites  seldom  occurs. 


158  PRACTICE    OF    MEDICINE. 

Prognosis.  Unfavorable.  The  progress  is  rapid  or  slow,  depend- 
ing upon  the  cause. 

Treatment.  No  specific.  Prof.  Da  Costa  recommends  ammonii 
chloriditm,gx.  x-xx  (0.6-1.3  Gm.),  three  times  daily,  for  several  weeks, 
then  change  for  the  same  length  of  time  to  syrupus  ferri  iodidum, 
beginning  with  n\^x  (0.6  Cc),  gradually  increased  to  fSj  (4  Cc.)  after 
meals,  then  to  the  former  again,  and  so  on,  for  months.  Life  may 
be  prolonged  by  the  use  of  ferrum,  syrupus  calcii  lactophosphas, 
and  oleum  morrhuce. 


HEPATIC  CANCER. 

Synonym.     Carcinoma  of  the  liver. 

Definition.  A  peculiar  morbid  growth,  progressively  destroying 
the  hepatic  tissue ;  characterized  by  disorders  of  digestion,  anaemia, 
emaciation,  jaundice,  and  ascites,  and  terminating  in  the  death  of  the 
patient. 

Causes.  Hereditary,  when  it  is  termed  primary  cancer;  exten- 
sion from  other  organs,  termed  secondary  cancer.  It  is  a  disease  of 
advanced  life,  from  forty  to  sixty  years  of  age. 

Pathological  Anatomy.  The  most  common  variety  of  cancer 
of  the  liver  is  a  compound  of  the  medullary  and  scirrhus. 

The  cancer  cells  develop  from  the  interlobular  connective  tissue, 
and  as  they  grow  the  hepatic  cells  atrophy,  the  result  of  the  pressure 
of  the  new  growth.  The  branches  of  the  hepatic  artery  enlarge 
and  permeate  the  growth,  while  the  branches  of  the  portal  vein 
are  compressed  and  atrophied,  thereby  blocking  up  the  portal  circu- 
lation. 

The  cancer  may  develop  in  nodules  or  masses,  or  maybe  diffused  ; 
the  nodules  vary  in  size,  and  those  on  the  surface  are  rounded,  with 
a  central  umbilication.  The  peritoneum  is  adherent,  cloudy,  and 
thickened. 

Symptoms.  The  development  of  hepatic  cancer  is  preceded 
by  a  history  of  dyspepsia,  flatulency,  and  constipation.  Uneasiness, 
weight,  and  pain,  increased  by  pressure,  are  noticed  ;  jaundice, 
ascites,  occasionally  intestinal  heviorrhages,  emaciation,  feebleness, 
anccmia,  cold,  dty,  harsh  skin,  pinched  features,  with  dejected,  worn 
expression.     Fever  never  occurs  unless  there  is  some  complicating 


DISEASES   OF  THE   KIDNEYS.  159 

condition.  The  hepatic  dullness  is  increased,  with  pains  on  palpa- 
tion, and  the  liver  is  indurated,  irregular,  and  nodulated. 

The  duration  is  less  than  a  year  from  the  time  the  disease  is  recog- 
nized. 

Diagnosis.  The  points  of  differentiation  are  the  age,  cachexia, 
pain,  and  tenderness,  enlarged  liver  with  hard  nodules,  and  rapid 
emaciation  and  progress  of  the  disease. 

Prognosis.     Always  terminates  in  death. 

Treatment.  Early  symptomatic.  Sooner  or  later  opium  must  be 
used  to  relieve  the  terrible  and  persistent  pain. 


DISEASES  OF  THE  KIDNEYS. 


THE  URINE. 

The  normal  quantity  of  urine  voided  varies  from  forty  to  fifty 
ounces  (1200-1500  Cc.)  in  the  twenty-four  hours  ;  it  is  decreased  by 
free  perspiration  and  increased  hy  chilling  of  the  skin. 

Within  the  twenty-four  hours,  the  least  urine  is  passed  during  the 
night  or  in  the  early  morning,  very  much  the  greater  portion  being 
passed  during  the  course  of  the  day. 

The  normal  color  is  light  amber,  due  to  urobilin  ;  the  color  deepens 
if  the  quantity  voided  be  decreased,  and  vice  versa.  In  nearly  all 
normal  urine  a  cloud  of  mucus  forms  after  standing  a  short  time. 

The  normal  reaction  is  slightly  acid,  due  to  the  acid  sodic  phos- 
phate, uric  and  hippuric  acids.  After  meals  it  may  be  neutral  or 
even  alkaline. 

The  normal  specific  gravity  varies  from  1.015  to  1.02;  it  is  low 
when  an  increasecJ  quantity  is  passed,  and  high  when  the  quantity  is 
diminished. 

The  normal  odor  of  urine  is  a  peculiar,  well-known,  aromatic  one ; 
it  is  altered  by  certain  foods,  such  as  the  violet  stench  after  eating 
asparagus,  and  the  garlicky  odor  after  using  garlic. 


IGO 


rRACTICK    OK    MTDICINE. 


The  most  important  organic  and  inorganic  solid  constituents  held 
in  solution,  are  un-a  (the  index  of  nitrogenous  excretion),  from  308 
to  617  gr.  daily  ;  uric  acid,  from  6  to  12  gr. ;  urates  of  sodium,  ammo- 
nium, potassium,  calcium,  and  magnesium,  from  9  to  14  gr.;  phos- 
phates of  sodium,  etc.,  from  12  to  45  gr.,  and  chlorides  of  sodium, 
etc.,  from  154  to  237«gr.  daily. 


I.  Quantitative  test 
for  urea  by  hypobro- 
mite  of  sodium 
(Davy's  method). 


II.  Tests  for  urates 
and  uric  acid  by  nitric  < 
acid. 


Fill  a  graduated  glass  tube  one-third  full 
oi  mercury,  and  add  one-half  drachm  of  the 
24  hours'  urine;  then  fill  the  tube  ever.l\ 
full  with  a  saturated  solution  of  hypobromite 
of  sodium,  and  close  it  imtnediately  with  the 
thumb;  invert  the  tube  and  place  its  open 
end  beneath  a  sat.  sol.  of  chloride  of  sodium  ; 
the  mercury  flows  out  and  is  replaced  by  the 
solution  of  salt;  nitrogen  gas  \s  disengaged 
from  the  urea  in  the  upper  part  of  the  tube. 
Each  cubic  inch  of  gas  represents  0.645  gr. 
of  urea  in  the  half-drachm,  from  which  the 
^  amount  passed  in  24  hours  may  be  calculated. 

Urine  containing  an  excess  of  urates  and 
uric  acid,  on  cooling  precipitates  them  (viz. : 
"  brickdust  deposits  "  in  "  pot  dechambre  "). 
i^a/ dissolves  them  to  a  certain  extent. 

Nitric  acid  deprives  the  soluble  neutral 
urates  of  their  bases,  and  produces,  at  first, 
a  faint,  milky  precipitate  of  amorphous  acid 
urates  ;  adding  more  acid,  the  still  less  solu- 
ble red  crystals  of  uric  acid,  resembling  cay- 
enne pepper,  are  deposited. 

Put  a  small  quantity  of  nitric  acid  in  a 
test-tube,  and  pour  the  urine  carefully  down 
the  sides  of  the  tube  upon  it,  and  a  zone  of 
yellowish-red  uric  acid  arfd  altered  coloring 
matter  will  form  at  their  union  ;  and  a  dense, 
milky  zone  of  acid  urates  above  this,  which, 
however,  dissolve  upon  agitation.  (See  al- 
bumin test.) 


DISEASES   OF   THE    KIDNEYS. 


161 


III.  Ouantitativetest 
for  uric  acid  by  nitric  ^ 
acid. 


IV.  Test  for  the 
earthy  and  alkahne 
phosphates  by  the 
magnesium  fluid. 


V.  Test  for  the  chlo- 
rides by  nitrate  of  sil- 
ver. 


VI.  Test  for  mucus 
by  acetic  acid  and  liq-  ^ 
uor  iodi  comp. 


11 


To  three  ounces  of  the  24  hours'  urine 
(after  being  shghtly  acidulated,  boiled,  and 
filtered  while  hot)  add  one-te7ith  as  much 
jiitric  acid ;  place  in  a  cool  place  for  24 
hours,  then  collect  the  deposit  of  uric  acid  on 
a  weighed  filter,  wash  it  thoroughly,  and  dry 
at  212°  F.  The  increased  weight  represents 
^  the  uric  acid  in  part  excreted,  approximately. 

Heat  or  liquor  potasses  increases  the  cloud- 
iness caused  by  earthy  calcium  and  magne- 
sium phosphates.  Acetic  or  nitric  acid  clears 
it  by  dissolving  them. 

To  two  ounces  of  urine  add  one-third  as 
much  of  the  following  solution  ;  R .  Magnesii 
sulph.,  ammonii  chloridi  puri,  liquor  ammo- 
nise,  each  one  part ;  aquae  destil,,  eight  parts ; 
if  the  precipitate  has  a  milky,  cloudy  appear- 
ance, the  quantity  of  phosphates  is  normal ; 
if  creamy,  the  phosphates  are  in  excess. 

To  a  convenient  quantity  of  urine  add  a 
small  quantity  of  nitric  acid,  to  prevent  the 
formation  of  the  phosphates  and  other  salts 
of  silver  ;  filter  this,  if  cloudy ;  add  to  this 
07ie  drop  of  a  solution  of  nitrate  of  silver  (i 
part  to  8)  and  the  precipitate  of  white  cheesy 
lumps  of  chlorides  of  silver  denotes  that  the 
amount  of  chlorides  is  normal ;  if,  however, 
only  a  faint  milkiness  occurs,  the  chlorides 
y  are  diminished. 

Mucus  alone  is  not  visible,  but  causes 
cloudiness,  from  having  entangled  mucous 
or  pus  corpuscles,  epithelium,  granules  of  so- 
dium urate,  crystals  of  oxalate  of  lime,  and 
uric  acid  in  various  amounts. 

Add  to  the  urine  a  little  acetic  acid,  or,  in ' 
addition,  a  few  drops  of  liquor  iodi  comp., 
when  threads  and  bands  of  mucift  are  made 
visible.  The  addition  of  nitric  acid  dissolves 
them. 


162 


PRACTICE    OK    MKDICINE. 


VII.  Test  for  a/btt- 
min  by  heat  and  nitric  < 
acid. 


Slightly  acidulate  the  urine,  if  necessary, 
by  addition  of  nitric  or  acetic  acid,  and  boil ; 
this  causes  a  white  deposit  of  coagulated 
albiimm,  which  is  not  dissolved  by  nitric 
acid,  unless  the  acid  is  in  excess. 

Nitric  acid  causes  a  white  deposit  of 
coagulated  albumin,  which  is  dissolved  if  a 
large  excess  of  acid  be  added.  A  delicate 
test  is  to  put  the  nitric  acid  in  the  tube  first, 
and  then  gradually  pour  the  urine  down  the 
side  of  the  tube  upon  it,  when  a  white  zone 
or  ring  of  coagulated  albumin  appears.  Pre- 
caution, see  tests  Nos.  3,  4,  11,  and  13. 


VIII.  Test  for  a/^«- 
mift  by  picric  acid 
(saturated,  watery  so- 
lution). 


Pour  a  quantity  of  urine  into  a  test-tube, 
and  add  the  picric  acid  solution  drop  by  drop 
and,  as  it  passes  through  the  urine,  it  is  fol- 
lowed by  an  opaque  white  cloud  if  albumin 
be  present.  The  test  is  very  striking  and 
beautiful.  If  cloudiness  appears  some  time 
after,  instead  of  at  the  time,  it  shows  noth- 
ing. The  test  will  not  detect  as  small  an 
amount  of  albumin  as  heat  or  nitric  acid. 


IX.  Nitric  -  magne- 
sian  test  for  albumin. 
The  fluid  is  prepared 
by  mixing  1  part  of 
pure  nitric  acid  with  5  < 
parts  of  a  saturated 
solution  of  the  suK 
phate  of  magnesium, 
and  filtering. 


X.  Quantitative  test 
for  albumin.  Approxi- 
mately. 


One  drachm  of  the  reagent  is  poured  into 
a  perfectly  clean  test-tube;  the  urine  should 
be  allowed  to  trickle  slowly  down  upon  the 
fluid;  if  albumin  be  present  in  an  amount 
as  small  as  one  one-hundredth  of  one  per 
cent.,  this  test  will  show  a  compact,  dense, 
white  layer.  This  is  one  of  the  best  and 
most  reliable  tests  for  albumin. 

Add  a  few  drops  of  nitric  acid  to  a  pro- 
portion of  the  urine,  and  boil;  set  this  away 
for  24  hours,  and  the  proportionate  depth  of 
the  resulting  deposit  is  the  comparative  in- 
dication— viz. ;  %-%,  etc. 


DISEASES   OF   THE   KIDNEYS. 


163 


For  minute  traces  of  albumin  Millard's  fluid  may  be  used  ;  it  is  a 
delicate  test  and  requires  care.  The  fluid  consists  of  glacial  carbolic 
acid  (ninety- five  per  cent.),  3ij  (8  Cc.)  ;  pure  acetic  acid,  3vij  (28  Cc); 
liquor  potassse,  5'j,  3vj  (84  Cc). 

XI.  Test  for  blood  ^  i%cr/ or  «z7rzV  acz"^  causes  deposit  of  albu- 
by  heat  and  nitric  \  min,  with  the  coloring  matter  changed  to  a 
acid.  L  dirty  brown. 

^  Heat  the  urine,  then  add  caustic  potash 
and  heat  anew.  The  phosphates  are  thus 
precipitated,  taking  with  them  the  coloring 
matter  of  the  blood,  which  imparts  a  dit'iy, 
yellowish-red  color  to  the  sediment,  viewed 
by  reflected  light,  and  when  seen  by  trans- 
mitted light,  gives  a  splendid  blood-red 
color. 

Neither  the  coloring  matter  of  the  blood, 
nor  that  of  the  bile,  is  precipitated  with  the 
phosphates,  so  that  coloration  of  urine  which 
shows  this  reaction  cannot  be  ascribed  to 
the  presence  of  the  latter  pigments. 

When  the  quantity  of  blood  in  the  urine 
is  very  large,  it  is  of  a  dark  or  brownish-red, 
and,  after  standing,  forms  a  coagulum  of 
blood  at  the  bottom  of  the  vessel. 

Caution.  Heat  or  nitric  acid  causes  co- 
agfulation  of  the  albumin. 


XII.  Test  for  blood 
by  heat  and  caustic 
potash  (Heller's). 


XIII.  Test   for  pus 
by  liquor  potass^. 


XIV.  Test  for  bile 
by  "fuming"  or  red 
nitric  acid. 


Add  to  the  urine,  or  preferably  to  its  de- 
posit from  standing,  an  equal  volume  of 
■I  liquor  potasscE ;  when  well  mixed,  a  viscid 
gelatinous  fluid  or  mass  is  formed,  which 
pours  like  the  white  of  an  e^Z'  or  jelly. 

Allow  a  specimen  of  urine  and  a  few  drops 
of  red  "  fuming  "  «//rz"^  acid  to  gradually 
intermingle  on  a  porcelain  dish,  and  a  "play 
of  colors,"  green,  blue,  violet,  red,  ^v^A yellow 
or  brown  occurs,  if  biliary  coloring  matter  be 
present. 


]04 


PRACTICE    OF    MEDICINE. 


XV.  Test  for  bile 
pigment  by  pure  hy- 
drochloric and  pure 
nitric  acids  (Heller's). 


Pour  into  a  test-tube  about  i.6-f5  of  pure 
hydrochloric  acid,  and  add  to  it,  drop  by 
drop,  just  sufficient  urine  Xo  distinctly  color 
it.  The  two  are  mixed.  Then  drop  down 
the  side  of  the  test-tube  pure  nitric  acid, 
which  will  "  underlay  "  the  mixture  of  hydro- 
chloric acid  and  urine.  At  the  point  of 
contact  between  the  mixture  and  the  color- 
less nitric  acid  a  handsome  "  play  of  colors  " 
appears.  If  the  "underlying"  nitric  acid 
is  now  stirred  with  a  glass  rod,  the  set  of 
colors  which  were  superimposed  upon  one 
another  will  appear  alongside  of  each  other 
in  the  entire  mixture,  and  should  be  studied 
by  transmitted  light. 

If  the  hydrochloric  acid,  on  addition  of 
the  biliary  urine,  is  colored  reddish-yellow, 
the  coloring  matter  is  bilirubin;  if  it  is  col- 
ored ^r^^«,  it  is  biliTerdin. 


XVI.  Ttstiov  sugar 
by  liquor  potassae  and  * 
heat  (Moore's). 


Add  to  the  urine  half  its  volume  of  liquor 
potassce.  (^Caution.  This  w/a^y  give  a  white, 
flaky  precipitate  of  the  earthy  phosphates, 
which  should  be  removed  by  filtering.)  Now 
boil ;  this  causes,  at  first,  a  yellow-brownish 
color,  becoming  darker  if  much  sugar  is 
present,  due  to  glucic  and  finally  to  melassic 
acid. 


XVII.  Test  for 
sugar  by  subnitrate  of 
bismuth,  liquor  potas- 
sai  and  heat. 


Add  to  the  urine  half  its  volume  o{  liquor 
potassce,  and  then  a  little  bismuth  subnitrate, 
shake,  and  thoroughly  boil ;  the  presence  of 
sugar  reduces  the  salt  and  black  metallic 
bismjith  is  deposited,  or,  if  but  little  sugar,  a 
gray  deposit  occurs. 

Catition.     Albumin  must  be  absent. 


DISEASES    OF   THE   KIDNEYS. 


165 


XVIII.      Test  for 
sugar  by  a  solution  of 
cupric  sulphate,  liquor  < 
potassse,     and     heat 
(Trommer's). 


Add  to  the  urine  a  few  drops  of  a  solution 
oi  CKpric  sulphate,  and  then  its  own  volume 
oi  liquor  potasses.  {Caution.  On  first  addi- 
tion a  light  greenish  precipitate  occurs, 
which,  on  further  addition  of  the  reagent,  if 
sugar  or  certain  other  organic  matters  are 
dissolved,  giving  a  transparent  blue  liquid.) 
Now  boil,  and  a  yellowish  precipitate  of 
hydrated  cupric  stcboxide,  occurring  at  once, 
denotes  ihe.  presence  of  sugar. 

Caution.     Albumin  must  be  absent. 


XIX.  Quantitative 
test  {ox sugar  by  Pavy  s 
solution,  to  wit : 

R 

Cupric  sulphate,  320  gr. 
Neutral  potassic 

tartrate,  .  .  640  gr. 
Caustic  potash,  1 280  gr. 
Distilled  water,       20  f  5  . 

Keep  corked. 


Take  of  Pavy  s  solution  of  cupric  protox- 
ide, recently  prepared  (see  margin),  200 
minims  or  a  multiple  of  this  quantity,  and 
boil  in  a  porcelain  dish  ;  while  boiling,  add 
minim  by  minim,  from  a  measured  portion 
of  the  24  hours'  urine,  and  it  gives  2l yellow- 
ish precipitate  of  hydrated  cupric  suboxide, 
if  sugar  be  present. 

Note  carefully  the  gradual  disappearance 
of  the  blue  color,  and  when  completed  (best 
determined  by  looking  through  the  margin 
of  the  fluid  against  the  white  porcelain  dish), 
from  the  amount  of  urine  used  determine 
the  amount  of  sugar  passed  daily.  The 
quantity  of  urine  containing  one  grain  of 
sugar  being  just  sufficient  to  reduce  the  200 
minims  of  the  copper  solution. 


XX.  Quantitative 
test  for  sugar  by  fer- 
mentation and  the 
specific  gravity. 


Take  two  measured  specimens  from  the 
24  hours'  urine,  and  to  one  add  a  little  yeast. 
Place  each  specimen  in  a  temperature  of  75° 
to  80°  F. ;  in  24  hours  fermentatioft  hav- 
ing destroyed  the  sugar  in  the  one  contain- 
ing the  yeast,  the  difference  in  the  specific 
gravity  of  the  two  specimens  expresses  the 
number  of  grains  in  each  ounce  of  the  urine, 
approximately. 


166 


PRACTICE    OF    MEDICINE. 


XXI.  Tests  for  In- 
doxyl-potassium  sul- 
phate (Indican  ?). 

Note.— If  the  urine  con- 
tain albumin,  it  must  be 
removed  before  applying 
these  tests,  otherwise  the 
blue  color  often  arising 
from  the  mixture  of  hydro- 
chloric acid  and  albumin 
after  standing  may  prove 
misleading.— /"//''((y. 


XXII.         Ehrlich's 
diazo-reaction  test. 


I.  McMunns  Method :  Equal  parts  of 
urine  and  hydrochloric  acid, with  a  few  drops 
of  nitric  acid,  are  boiled  together,  cooled,  and 
agitated  with  chloroform.  The  fluid  is  col- 
ored violet,  and  shows  an  absorption  band, 
before  D,  due  to  indigo  blue,  and  another 
after  D,  due  to  indigo  red. 

II.  Taffe's  Method :  Mix  lo  Cc.  of  strong 
hydrochloric  acid  with  an  equal  volume  of 
urine  in  test-tube,  and  while  shaking  add, 
drop  by  drop,  a  perfectly  fresh  saturated 
solution  of  chloride  of  lime,  or  chlorine- 
water,  until  the  deepest  attainable  blue  color 
is  reached.  The  mixture  should  next  be 
agitated  with  chloroform,  which  readily  takes 
up  the  indigo  and  holds  it  in  solution.  The 
quantity  is  estimated  by  depth  of  blue  color. 

III.  Pour  4  Cc.  of  hydrochloric  acid  into  a 
small  flask,  and  while  stirring  add  from  lo 
to  20  drops  of  urine.  If  the  proportion  of 
indigo  be  above  normal,  the  resulting  color 
will  be  rather  light  yellow  ;  if  in  excess,  the 
acid  will  turn  violet  or  blue, — the  more  in- 
tense will  be  the  color  in  proportion  to  the 
quantity  present.  If  no  coloration  appears 
after  waiting  a  minute  or  two,  there  is  no 
excess,  no  difference  how  deep  a  color  may 
subsequently  appear. 

I.  Take  2  Gm.  (30  gr.)  of  sulphanilic  acid, 
50  Cc.  of  hydrochloric  acid,  and  1000  Cc.  of 
distilled  water. 

II.  Take  solution  sodium  nitrite  in  water 
of  the  strength  of  0.5  per  cent.  Place  fifty 
parts  of  No.  I  and  one  part  No.  II  in  a  test- 
tube  and  add  equal  amount  of  urine.  The 
entire  contents  is  rendered  strongly  alkaline 
by  strong  ammonia  water. 

If  the  diazo-reaction  occur,  the  mixture 
becomes  carmine  red  ;  now  shake  the  tube, 
and  if  the  red  color  is  seen  in  ihtfoavi,  the 
test  is  complete.  Allow  the  tube  to  stand  a 
day  and  a  green  precipitate  forms. 


DISEASES   OF   THE   KIDNEYS.  167 


CONGESTION  OF  THE  KIDNEYS. 

Synonyms.     Renal  hypersemia  ;  catarrhal  nephritis. 

Definition.  An  increase  in  the  amount  of  blood  in  the  vessels 
of  the  kidneys  ;  when  arterial,  it  is  termed  active  congestion;  when 
venoMS,  passive  co?tgestzon  ;  characterized  by  pain,  frequent  desire  for 
urination,  the  amount  of  urine  scanty,  high-colored,  occasionally 
containing  albumin  or  blood. 

Causes.  Active:  from  cold;  irritating  substances  eliminated  by 
the  kidneys,  as  turpentine,  copaiba,  cantharides,  carbolic  acid,  nitrate 
or  chlorate  of  potash  ;  during  the  eruptive  or  continued  fevers;  in- 
juries over  the  kidneys. 

Passive :  obstructive  diseases  of  the  heart  or  lungs,  pressure  of  the 
pregnant  uterus. 

Pathological  Anatomy.  The  kidneys  enlarge  and  increase 
in  weight ;  increased  redness  (the  color  being  bluish  li  passive),  with 
points  of  vascularity,  corresponding  to  the  Malpighian  bodies,  and 
occasionally  minute  ecchymoses.  The  abnormal  hyperaemia  causes 
a  catarrhal  state  of  the  ducts  of  the  pyramids,  with  shedding  of  their 
epithelium. 

If  mechanical  {passive)  obstruction  continues  for  some  time,  in- 
crease of  the  connective  tissue  with  consequent  induration  and  con- 
traction results,  or  a  form  of  chronic  Bright's  disease. 

Symptoms.  Active  variety :  pain  over  kidneys  and  following 
the  course  of  the  ureters  into  the  testicles  and  penis,  irritable  bladder, 
almost  constant  and  pressing  desire  for  urination,  the  tiri7ie  scanty, 
high-colored,  and  occasionally  bloody,  with  fibrin,  casts,  and  albumin  ; 
there  is,  as  a  rule,  no  pain  during  the  act  of  urination.  The  constitu- 
tional symptoms  are  headache,  slight  nausea,  vomiting,  and  a  general 
feeling  of  discomfort. 

If  the  condition  persist,  i7iflam7nation  of  the  kidney  results. 

Passive  :  the  kidney  changes  are  masked  by  the  lung  or  heart 
trouble,  until  dropsy,  scanty  high-colored  albumijious  urine  is  ob- 
served. 

Prognosis.  Active  :  if  recognized  and  properly  treated,  favorable. 

Passive  :  controlled  by  the  cause,  and  if  prolonged,  terminating  in 
interstitial  nephritis. 

Treatment.     The  most  important  indication  is  to  ascertain  and 


168  PRACTICE    OF    MEDICINE. 

remove  the  cause.  Rest  of  the  body  ;  dry  or  wet  cups  over  the  loins; 
dilute  the  urine  by  increasing  the  quantity  of  bland  fluids  consumed; 
salitie  purgLith'cs  ;  warm  bath  or  other  mild  diaphoretics.  lu/usutH 
digita/is  is  pre-eminently  the  remedy  for  congestion  of  the  kidneys; 
if  great  irritability  of  the  bladder,  campliora,  gr.  ij-iv  (0.13-0.26 
Gm.)  every  four  hours,  combined  with  morphince  sulp/ias,  gr.  -^\ 
(0.005-0.011  Gm.),  or  the  hypodermic  injection  of  morphina  sul- 
phas, gr.  -jV  (0.005  Gm  ). 

The  treatment  of  the  passive  form  resolves  itself  into  the  treatment 
of  the  cause,  remembering  that  there  is  too  much  blood  in  the  veins 
and  too  little  in  the  arteries.  There  are  three  ways  of  restoring  the 
circulation.  By  venesection,  opening  a  large  vein  ;  by  increasing  the 
power  of  the  heart  by  the  use  of  digitalis  or  strophanthus,  preferably 
the  first  named  ;  and  by  dilatation  of  the  capillaries  with  inhalations 
of  aviyl  nitrite  or  the  internal  use  of  spiritiis  glonoini  {miro-gXyctrxn 
I  per  cent,  solution),  TT\^j-iij  (0.06-0.18  Cc.)  every  four  hours.  The 
bowels  should  be  kept  soluble  by  salines. 


ACUTE  PARENCHYMATOUS  NEPHRITIS. 

Synon3rms.  Acute  Bright's  disease ;  acute  desquamative  ne- 
phritis ;  acute  tubal  nephritis  ;  acute  croupous  nephritis. 

Definition.  An  acute  inflammation  of  the  epithelium  of  the 
uriniferous  tubules  ;  characterized  by  fever,  scanty,  high-colored,  or 
smoky  urine,  dropsy,  with  more  or  less  constant  nervous  phenomena, 
the  result  of  acute  urzemia. 

Causes.  The  young  more  liable  than  the  aged ;  cold  and  ex- 
posure;  scarlatina,  diphtheria,  and  other  infectious  diseases;  per- 
sistent use  of  irritants,  as  turpentine,  canlharides,  phosphorus,  ginger, 
and  others.  Blows  and  injuries  of  the  back  have  caused  acute 
nephritis.  Pregnancy  is  not  an  uncommon  cause,  resulting  frequently 
in  puerperal  convulsions.     Malarial  poisoning. 

Patholo^cal  Anatomy.  The  kidneys  are  generally  swollen, 
engorged,  more  vascular,  and  of  red  color;  in  the  second  stage  the 
organ  remains  large,  irregularly  red,  especially  the  cortex ;  the 
tubules  are  engorged  and  filled  with  epithelium,  blood  corpuscles, 
and  fibrin.  The  capsule  is  easily  detached,  and  is  more  opaque  than 
normal. 


DISEASES   OF  THE   KIDNEYS.  169 

If  a  favorable  termination,  the  swelling  lessens,  the  vascnlarity 
diminishes,  the  tubules  returning  to  their  normal  condition. 

Symptoms.  In  mild  cases  the  slowly  developing  dropsy,  with 
attcetnia,  and  dyspnasa,  or  simply  shortness  of  breath,  with  weakness, 
are  the  only  clinical  phenomena  present,  the  diagnosis  being  con- 
firmed by  an  examination  of  the  urine.  Usually,  however,  begins 
suddenly.  Fever,  with  nausea  and  violent  and  persistent  vomiting, 
duWpain  over  the  kidneys,  following  the  ureters  ;  frequent  desire  to 
urinate  ;  diarrhoea  ;  s^ift  harsh  and  dry  ;  putse  quick,  tense,  and  full. 
Soon  dropsy  appears,  the  eyelids  and  face  become  puffy  and  swollen, 
followed  by  general  oedema  of  the  extremities,  scrotum,  and  abdo- 
minal walls.  If  the  attack  follow  scarlatina,  there  are  from  the  onset 
much  greater  pallor  and  general  debility. 

Uremic  symptoms  may  develop  any  time  during  the  attack. 

The  urine  is  of  high  specific  gravity,  1025  to  1030,  scanty,  smoky 
(like  beef  washings)  in  color,  due  to  the  presence  of  blood.  Albumin 
is  present  in  large  quantities,  and  the  microscope  reveals  casts  of  the 
uriniferous  tubules,  blood  corpuscles,  uric  acid,  urates,  oxalate  crys- 
tals, and  epithelium.  The  total  amount  of  urea  eliminated  during  the 
twenty-four  hours  is  lessened  from  one-fourth  to  one-half.  The 
amount  of  phosphates  and  chlorides  is  also  lessened. 

Duration  from  one  to  four  weeks. 

Complications.  Pericarditis,  pleuritis,  pneumonitis,  peritonitis, 
and  acute  ttrtztnia,  from  retention  and  decomposition  of  urea  in  the 
blood. 

Diagnosis.  The  history,  fever,  scanty,  smoky,  albuminous  urine, 
with  dropsy  beginning  in  the  face,  should  prevent  any  error. 

Albu7ni7iuria  may  be  confounded,  on  account  of  the  presence  of 
albumin  in  the  urine,  but  lacks  the  clinical  history,  usually  occurring 
in  the  course  of  some  constitutional  affection,  as  diphtheria,  cholera, 
)  ellow  fever,  or  erysipelas. 

Da  Costa  distinguishes  between  acute  Bright's  disease  and  acute 
nephritis  by  the  last  named  "  affecting  only  one  kidney,  by  much 
greater  pain  and  tenderness  in  the  lumbar  region,  by  the  retraction  of 
the  testicle,  and  by  the  higher  degree  of  febrile  excitement.  Then,  tod, 
the  deeply  colored  urine  which  is  voided  contains  little  or  no  albumin." 

Prognosis.  Favorable.  Majority  of  cases  recover  under  prompt 
treatment.  Rarely  passes  into  chronic  Bright's  disease.  Urcemic 
symptoms  add  to  the  gravity  of  the  prognosis. 


no  PRACTICE    OF    MEDICINE. 

Treatment.  Absolute  rest  in  bed  until  all  symptoms  have  disap- 
peared. A  strictly  milk  diet  is  the  most  suitable,  but  if  there  is  much 
depression  and  weakness,  may  add  animal  broths  and  oysters.  No 
tea,  coffee,  or  stimulants.  Water  can  be  used  ad  libitum.  Cream  of 
tartar  lemonade  is  a  useful  as  well  as  pleasant  drink.  Locally,  dry 
cups  over  the  kidneys,  followed  by  poultices — a  digitalis  poultice 
being  of  great  value.  A  poultice  oi  jaborandi  leaves  and  flaxseed, 
half  and  half,  will  increase  the  action  of  the  kidneys. 

The  bowels  should  be  kept  soluble  with  morning  doses  of  salines 
or  pulv.  jalapa  comp.,  3j  (4  Gm.),  in  water  before  breakfast,  or 
elaterium,  gr.  ^  (o.oii  Gm.),  repeated  p.  r.  n.  Free  action  of  the 
bowels  assists  in  relieving  the  overtaxed  kidneys,  and  conjoined 
with  free  diaphoresis  seems  almost  indispensable  in  acute  nephritis. 
Magnesii  sulphas,  in  small  and  repeated  doses,  is  a  valuable  cathartic 
in  nephritis,  as  it  acts  upon  the  kidneys  as  well  as  the  bowels. 

The  most  efficient  diaphoretics  are  the  hot-air  bath  or  pack,  or  the 
wet  sheet  and  blanket  bath,  stimulating  the  peripheral  circulation,  after 
free  sweating  has  occurred,  by  rubbing  with  alcohol  and  water.  For 
drugs,  one  of  the  very  best  is  spiritus  cetheris  nitrosi,  tt\^v-xxx  (0.3-2 
Cc),  according  to  the  age.  Extractum  pilocarpi  fluidum,  Tt\^v-xxx 
(0.3-2  Cc),  according  to  the  age,  every  three  or  four  hours,  is  an 
excellent  diaphoretic  ;  but  as  it  is  generally  conceded  that  pilocarpus 
acts  better  when  administered  subcutaneously,  employ  pilocarpincB 
hydrochloras,  gr.  Y^  (o.oi  i  Gm.),  repeated  p.  r.  n.,  by  the  hypodermic 
method.  Another  valuable  diaphoretic  is  vinum  ipecacuanhce,  Tt\j- 
iij  (0.06-02  Cc),  every  half  hour  or  so;  combined  with  sweet 
spirits  of  nitre  and  neutral  mixture  it  forms  an  excellent  combination. 

Diuretics  are  of  great  value,  indeed,  often  indispensable,  in  acute 
nephritis.  Digitalis  is  the  most  reliable  diuretic  in  this  condition,  and 
in  the  form  of  an  infusion.  The  following  formula  of  Millard's  is 
suitable  in  the  majority  of  cases  : 

R.     Tinct.  digitalis, f  .^  ss  15.  Cc. 

Aceti  .scili;^;, f .^  'ss  45.  Cc. 

Spts.  a'tlieris  nitrosi, fS'j  ^-  Cc. 

SiG. — Teaspoonful  every  two  to  four  hours,  in  water. 

The  following  combination  has  given  excellent  results  : 

li .      Potassii  acetat., ,^  iv  15.  Gm. 

Inf.  digital., f.^i'j  9°-  Cc. 

Liq.  potassii  citratis,      f^'U  9°-  Cc. 

SiG. — Tablespoonful  every  two  to  four  hours,  in  water. 


DISEASES   OF  THE  KIDNEYS,  171 

Other  reliable  diuretics  are  digitalinum  (cryst.),  gr.  y^^  (0.00065 
Gm.),  caff'eincB  citrata,  gr.  ij-iv  (0.13-0.26  Gm.),  or  sparteince  sulphas, 
gr-  Vi-Y^  (0.02-0.03  Gm.). 

If  urasmic  symptoms  develop,  treat  according  to  directions  given 
in  that  section. 

As  soon  as  the  blood  disappears  from  the  urine,  a  course  oift-rrum, 
in  the  shape  of  Baskam's  Jtiixlure,  until  albumin  disappears  and 
health  is  restored.  The  following  is  the  formula  of  Basham's  mix- 
ture : 

R  •     Liq.  ammon.  acetat., f^^j  iSo.  Cc. 

Acid,  acetic, f^iij  I2.  Cc. 

Tinct.  ferri  chlor., i'7,v  20.  Cc. 

Alcoholis, f .1  ij  60.  Cc. 

Syrup., ^S^^  120.  Cc. 

AquEe, f^iv  120.  Cc.                 M. 

SiG. — Dose,  f  3J-f^j,  well  diluted. 

The  addition  of  one  minim  (0.065  Cc.)  spiritus  glonoini  to  each 
dose  of  Basham's  mixture  increases  its  nephritic  action. 

Dr.  James  Tyson,  than  whom  there  is  no  greater  authority  in 
nephritic  conditions,  strongly  urges  the  use  of  infusum  digitalis  in- 
stead of  the  tincture.  He  also  recommends,  as  an  admirable  diuretic 
combination,  Trousseau's  diuretic  wine,  viz. : 

K.     Junip.  contus, ^x  40.  Gm. 

Pulv.  digitalis, ^ij  8.  Gm. 

Pulv.  scillae, ^j  4.  Gm. 

Vin.  xerici, Oj  473-  Cc. 

Macerate  for  four  days  and  add 

Potassii  acetatis, ^iij  12.  Gm. 

Express  and  filter. 

SiG. — Tablespoonful  three  times  a  day  for  an  adult. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms.  Chronic  Bright's  disease ;  chronic  croupous  ne- 
phritis ;  chronic  tubal  nephritis ;  chronic  albuminuria ;  large  white 
kidney. 

Definition.  A  chronic  inflammation  of  the  cortical  and  tubular 
structure  of  the  kidneys ;  characterized  by  albuminous  urine,  dropsy, 
increasing  anaemia,  with  attacks  of  acute  uramia. 


172  PRACTICE    OF    MEDICINE. 

Causes.  Rarely  follows  the  acute  form,  but  in  ever  so  many 
cases  the  etiology  is  unknown,  and  in  the  vast  majority  of  cases  it  is 
primarily  chronic  or  subacute;  syphilis;  chronic  malaria;  alcoholic 
excesses;  chronic  mercurialism  ;  lead  poisoning  ;  opium  habit ;  pro- 
tracted suppuration;  phthisis;  hepatic  disorders;  pregnancy;  some 
undetermined  nervous  condition. 

It  is  a  disease  of  the  young,  rarely  occurring  after  forty.  Princi- 
pally occurring  in  males. 

Pathological  Anatomy.  A  large  white,  or  yellowish  white, 
smooth  kidney,  often  twice  the  normal  size.  The  capsule  is  nowhere 
adherent  to  the  organ.  Upon  section,  considerable  tumefaction  of 
the  cortical  substance  and  the  rarity  of  vascular  striae  are  recognized. 
The  medullary  substance  shows  no  appreciable  alteration,  its  color 
being  normal.  The  convoluted  tubes  are  irregularly  dilated  and 
thickened,  and  filled  with  broken-down  granulated  epithelium  and 
fibrinous  casts.  In  pronounced  cases  there  is  fatty  degeneration  of 
the  tubular  epithelium. 

"  The  intertubular  matrix  is  greatly  thickened — a  change  due  to 
hyperplasia  of  the  connective-tissue  elements,  to  the  migration  of  the 
white  corpuscles  and  their  subsequent  multiplication  and  fatty  trans- 
formation, and  to  a  quantity  of  fluid  exudation,  the  product  of  the 
increased  pressure  in  the  veins." 

Symptoms.  The  onset  is  gradual  and  insidious,  and  the  affec- 
tion is  seldom  recognized  until  the  appearance  of  dropsy,  which, 
beginning  under  the  eyes  and  in  the  face,  extends  all  over  the  body, 
causing  dyspnoea  from  ascites  or  hydrothorax ,  although  in  many  cases 
the  dropsy  may  be  a  late  symptom,  the  patient  becoming /^/.f,  debili- 
tated, and  suffering  from  cardiac  palpitation,  increasing  dyspnoea  on 
exertion,  and  vomiting,  all  gradually  developing  without  apparent 
cause ;  also  headache,  vertigo,  and  defective  vision.  The  urine  is 
scanty,  high-colored,  albuminotis ,  and  under  the  microscope  showing 
hyaline  and  granular  tube  casts,  granular  epithelium,  and  if  fatty  de- 
generation ozcMx,  fatty  tube  casts  and  oil  globules.  The  increase  above 
the  normal  amount  of  the  urine,  as  the  disease  progresses,  must  not  be 
forgotten  when  the  specific  gravity  is  low,  1.010-1.015,  and  the  quan- 
tity of  albumin  is  increased.  The  normal  constituents  of  "the  urine, 
and  particularly  urea,  are  diminished.  Irritable  bladder  is  a  very 
constant  symptom,  beginning  very  early  in  course  of  the  disease.  In 
the  hemorrhagic  form  the  urine  almost  constantly  contains  blood. 


DISEASES   OF  THE   KIDNEYS,  1Y3 

Ancemia  is  pronounced,  from  the  large  waste  of  albumin.  Gastro- 
intestinal disorders  and  various  neuralgic  pains  are  common  occur- 
rences. Cardiac  hypertrophy  is  of  common  occurrence.  Bronchial 
catarrh^  with  slight  oedema  of  the  larynx,  causing  husky  voice,  are 
frequent  complications.  Amaurosis,  the  result  of  neuro-retinitis, 
occurs  in  a  greater  or  less  degree  in  all  pronounced  cases.  Urcemic 
symptoms  occur  and  especially  tiraviic  asthma  (renal  asthma). 

Da  Costa  calls  attention  to  a  temporary  loss  of  vision,  soon  returning 
and  again  recurring,  in  a  well-marked  case  of  this  disease. 

Complications.  Pneumonia,  pleuritis,  pericarditis,  peritonitis, 
meningitis,  and  cardiac  hypertrophy. 

Prognosis.  Not  unfavorable,  unless  the  urine  persistently  con- 
tains a  large  number  oi fatty  tube  casts  and  oil  globules.  Relapses  are 
frequent,  but  many  complete  (?)  recoveries  are  recorded.  I  have  seen 
four  apparent  recoveries,  one  after  twelve  months*  duration,  another 
after  two  years'  duration,  and  still  another  after  five  years'  duration, 
no  return  showing  itself  after  two  years.  The  secondary  contraction 
of  the  kidneys  must  always  be  kept  in  mind,  the  particular  symptoms 
of  which  are  increased  flow  of  low  specific  gravity,  urine  with  small 
amount  of  albumin,  and  hypertrophy  of  left  ventricle,  with  accen- 
tuated aortic  second  sound. 

Treatment.  It  is  to  be  borne  in  mind  that  the  course  of  a  case 
of  chronic  Bright's  disease  is  not  continuously  downward  ;  periods  of 
remission  often  follow  the  most  aggravated  symptoms,  the  patient 
and  his  friends  being  buoyed  with  the  hope  of  an  early  recovery, 
when,  suddenly,  an  attack  of  acute  ursmia  terminates  life. 

A  patient  with  chronic  Bright's  disease  should,  as  far  as  possible, 
be  relieved  from  all  cares  of  business  and  spend  a  goodly  portion  of 
time  in  bed. 

The  diet  is  of  prime  importance.  It  may  consist  of  an  absolute 
milk  regimen,  pure,  or  prepared  as  most  palatable,  or  an  exclusive 
lean  meat  diet,  prepared  by  finely  chopping,  removing  all  fibrous  and 
fatty  portions,  boiled  quickly,  salted  to  taste,  and  served  hot — the  so- 
called  "  Salisbury  steaks."  The  use  of  half  a  pint  of  hot  water, 
acidulated  with  lemon,  before  each  meal  is  valuable. 

The  use  of  diaphoretics  and  hydragogue  cathartics  are  only  indi- 
cated when  the  dropsy  is  marked,  the  skin  harsh  and  dry,  the  urinary 
secretions  scanty,  and  ursemic  symptoms   are  threatening. 

Diuresis  should  be  promoted,  if  the  secretion  of  urine  is  scant,  by 


174  PRACTICE    OF    MKniCINK. 

digitalis,  caffeines  ciirata,  or  sparteina:  sulphas,  internally  or  hypo- 
dermic.iUy,  or  spiritus glonoini,  and  dry  cups  and  poultices  over  the 
loins,  and  the  use  of  the  normal  salt  solution  slowly  injected  into  the 
bowels.  The  following  is  a  good  combination  for  scanty  urine  and 
costive  bowels : 

JR.     Tlydrargyri  chlor.  mitls, 

Pulv.  scHIk, 

Pulv.  digital., .14    gr.  j  aa  .065  Gm. 

F     pil. 

SiG. — Three  times  daily  for  a  few  days. 

An  excellent  plan  to  promote  diuresis  and  diaphoresis  in  all  forms 
of  nephritis  is  by  the  use  oi  pilocarpus  locally.  I  have  used  the  fol- 
lowing ointment  for  several  years  with  invariable  success  : 

R.      Pilocarpine  nitrat., gr.  j-iij  .065-.2  Gm. 

Ung.  petrolei,      5J  30.  Gm.    M. 

SiG. — Apply  piece  size  hickory-nut  over  dorso-lumbar  region";,  night  and 
morning,  covering  surface  with  layer  of  cotton  or  gauze. 

Iron  is  preeminently  the  drug  for  this  variety  of  Bright's  disease, 
using  the  tinctura  ferri  chloridum.  Large  doses  are  not  needed. 
Combined  with  spiritus  aetheris  nilrosi  or  in  the  form  of  Basham's 
mixture,  makes  an  excellent  combination  for  the  ferrum  ;  one  minim 
(0.06  Cc  )  spiritus  glonoini  added  to  each  dose  of  the  ferrum  com- 
bination is  useful. 

The  ancBviia  is  to  be  treated  by  oleum  morrhuce,  arsenicum,  and 
ferruvt,  an  excellent  formula  for  the  latter  being — 

K.     Str)xhnince  sulph., g"^-  %  .016  Gm. 

Tinct.  ferri  chloridi, f  3  ij  8.         Cc. 

Acidi  acetici  purse, f^j  4-         Cc. 

Curacore  albae, f^j  30.         Cc. 

Liq.  ammonii  acetat.,     .    .     adf5vj  180.         Cc.  M. 

SiG. — Tablespoonful  every  five  hours,  followed  by  a  glass  of  cold  water. 

To  check  the  waste  of  albuviin,  a  difficult  matter,  the  following 
remedies  have  been  used  with  more  or  less  success :  ergota,  quinince 
sulphas,  acidian  gallicum,  sodii  benzoas,  tinctura  cantharidis,  or 
potassii  iodiduin. 

For  dropsy,  purgatives,  such  ■&.%  pulvis  jalapcz  co?npositus,  tnagnesii 
sulphas,  and  alkaline  mineral  waters  or  the  vapor  baths,  or  pilocar- 
pines hydrochloras,  gr.  y^  (0.008  Gm.),  repeated  if  not  much  cardiac 
depression,  or  combining  pulvis  ipecacuanhcB  et  opH,  gr.  iij  (0.2  Gm.), 


DISEASES   OF   THE   KIDNEYS.  175 

with  potassii  nitras,  gr.  iij  (0.3  Gm.),  every  two  or  three  hours, 
or  diuretin,  gr.  xx  (1.3  Gm.),  after  meals;  what  is  most  valuable  is 
the  hot-air  bath  ox  pack.  If  there  be  great  distention  of  the  serous 
cavities,  interfering  with  the  respiration,  the  aspirator  should  be  used. 
Puncture  of  the  skin  may  be  necessary  at  times,  and  it  is  well 
accomplished  with  an  ordinary  cambric  needle. 

Cases  due  to  syphilis,  if  the  loss  of  renal  structure  is  slight,  are 
cured  by  a  course  of  hydrargyri  corrosivum  chloridum  and  potassii 
iodidian,  with  oleum  morrhucB. 


INTERSTITIAL   NEPHRITIS. 

Synonyms.  Chronic  Bright's  disease  ;  sclerosis  of  the  kidneys; 
contracted  kidney  ;  small  red  kidney  ;  gouty  kidney. 

Definition.  An  inflammation  of  the  intervening  connective 
tissue  of  the  kidney,  chronic  in  its  progress,  resulting  in  an  induration 
or  hardening,  with  contraction  of  the  organ  ;  characterized  by  the  fre- 
quent voiding  of  large  amounts  of  pale,  albuminous  urine,  of  low 
specific  gravity,  disorders  of  the  gastro-intestinal  canal  and  nervous 
system,  and  a  strong  tendency  to  cardiac  hypertrophy  and  changes 
in  the  vessel.  Cases  of  interstitial  nephritis  are  not  uncommon  in 
which  albumin  is  never  detected  in  the  urine. 

Causes.  A  disease  of  middle  life,  from  forty  to  sixty  years. 
Gout  a  common  cause  ;  lead  cachexia  ;  syphilis  ;  alcoholism  ;  opium 
habit;  following  chronic  cystitis  and  chronic  gonorrhoea;  long-con- 
tinued worry,  anxiety,  or  grief;  alterations  in  the  renal  ganglionic 
centres  (Da  Costa  and  Longstreth).  Hereditary  influence  (Tyson), 
secondary  to  chronic  cardiac  disease.  Hepatic  disorders,  as  the 
functions  of  the  liver  and  kidneys  are  closely  related.  A  functional 
disorder  of  the  liver,  if  not  checked,  leads  to  organic  kidney  disease. 

"  Renal  degeneration  is  a  consequence  of  the  long-continued 
elimination  of  products  of  faulty  digestion  through  the  kidneys." 
Uric  acid  is  a  nephritic  irritant. 

"  There  is  a  tendency  to  overgrowth  in  the  interstitial  tissue  of  the 
kidney,  as  of  other  organs,  in  old  age.  Hence  the  term  senile  atrophy 
of  the  kidney.  It  is  not  safe,  therefore,  to  call  every  instance  of  atro- 
phied kidney  met  in  the  post-mortem  room  a  case  of  interstitial 
nephritis."    (Tyson.) 

Pathological  Anatomy.     The  kidneys  are  increased  in  size. 


176  PRACTICE    OF    MEDICINE. 

The  capsule  is  thickened,  opaque,  and  adherent.  The  surface  of 
the  kidney  is  granular,  with  cysts  of  various  sizes,  of  transparent  color, 
scattered  irregularly  over  the  surface.  On  section  the  tissue  of  the 
kidney  is  tough  and  resistant.  The  cot/ical  portion  is  thin,  from 
atrophy,  being  only  a  line  or  two  in  thickness.  The  connective  tissue 
is  greatly  thickened,  compressing  the  tubules  into  mere  threads,  the 
glomeruli  ht'xng  grouped  together  in  bunches,  owing  to  the  wasting  of 
the  intermediate  tubes.  The  color  varies  from  a  darkish  brown  to  a 
yellowish  gray,  according  to  the  amount  of  blood  in  the  organ. 

The  left  side  of  the  heart  is  hypertrophied,  and  there  is  also  hyper- 
trophy of  the  muscular  fibre  of  the  arterioles  throughout  the  body ; 
if  the  case  is  protracted,  the  hypertrophied  tissues  undergo  fatty 
degeneration.  Cardiac  degeneration  with  arterio-capillary  sclerosis  or 
fibrosis  is  associated  with  advanced  nephritis. 

In  many  cases  there  occur  fatty  degeneration  of  the  retinal  tissues, 
or  sclerosis  of  the  nerve-fibre  layer,  changes  which  are  termed 
retinitis  albicminurica. 

The  "ganglionic  centres  "  undergo  fatty  degeneration  and  atrophy 
(Da  Costa  and  Longstreth). 

Apoplexy  is  a  frequent  termination  of  interstitial  nephritis,  the  rup- 
ture of  a  cerebral  vessel  suggesting  it  to  be  a  disease  of  degeneration. 

Symptoms.  Onset  insidious,  and  often  marked  alterations  in 
the  kidneys,  heart,  and  vessels  have  occurred  before  the  disease  is 
recognized.  There  are  no  characteristic  early  symptoms  in  the 
majority  of  cases,  the  disease  being  apparently  latent  until  some 
special  outbreak  causes  a  more  thorough  examination  of  the  patient, 
when  interstitial  nephritis  is  detected. 

Any  of  the  following  symptoms  may  first  attract  attention  :  Frequent 
tnicturition;  increased  amount  of  urine,  fifty  to  ninety  ounces,  acid, 
and  oi  3l  pale  color;  low  specific  gravity,  1005-1015  ;  containing  a 
small  amount  of  albianin,  which  may  be  absent  for  days ;  occasional 
epithelial  cells  and  hyaline  diwd  pale  granular  casts.  No  dropsy,  but 
a  little  puffiness  and  cedema  of  the  conjunctivcB — the  Bright's  eye. 
Disorders  of  vision.  Forcible  cardiac  action  with  high  arterial 
tension,  due  to  left  cardiac  hypertrophy,  which  is  an  almost  constant 
condition.  Attacks  of  vertigo  ;  headache  ; /wAa/zV^w^  in  the  head, 
neck,  and  other  parts  of  the  body,  and,  as  the  disease  progresses, 
cardiac  distress,  dyspnoea,  and  palpitation  occur.  A  reduplication 
of  the  first  cardiac  sound  is  common  ;  the  second  aortic  sound  is 


DISEASES    OF   THE   KIDNEYS.  177 

accentuated  and  the  pulse  is  hard  and  resisting,  indicating  high 
tension  and  thickening.  "Sclerosis  is  distinguished  from  tension  by- 
obliterating  the  blood  current  by  pressure  and  feeling  the  artery 
beyond.  The  sclerosed  vessel  continues  tangible,  that  of  high 
pressure  disappears."  (Tyson.)  Disordered  vision;  attacks  of  epistaxis 
and  disordered  stomach.  Progressive  anaemia  is  a  frequent  symptom, 
with  a  sense  oi greal  weakness.  Any  of  the  following  symptoms,  the 
result  of  urcemia,  may  occur :  Persistent  dyspepsia,  occasional  vom- 
iting, regardless  of  food  ;  headache,  vertigo,  and  stupor,  ox  drowsifiess ; 
violent  itchijig  of  the  skin  ;  tremors,  convulsio7is,  epileptic  seizures, 
or  apoplectic  attacks. 

The  body  weight  declines,  the  skin  is  dry  and  scurfy,  the  strength 
fails,  and  shortness  of  breath  on  exertion  is  present. 

Albumin  may  be  absent  from  the  urine  throughout  the  entire  course 
of  interstitial  nephritis,  and  casts  be  only  occasionally  detected  after 
many  trials,  and  yet  the  disease  progresses  to  a  fatal  termination. 

Towards  the  termination  of  the  disease  the  urine  diminishes  in 
quantity,  specific  gravity  increases,  and  the  casts  increase  in  number 
and  variety,  dark  granular  and  blood  casts  often  being  observed. 

The  termination  is  usually  by  convulsions,  coma,  and  death. 

Complications.  Bronchitis  ;  pneumonitis  ;  pleuritis  ;  pericar- 
ditis ;  cardiac  hypertrophy.     Pericarditis  is  always  fatal. 

Diagnosis.  Interstitial  nephritis  is  most  likely  to  be  confounded 
with  parenchymatous  nephritis.  The  following  table  from  Millard 
presents  the  most  important  point  of  difference  between  the  two  : 

In  Chronic  Croupous  Nephritis,  In     Chronic     Interstitial    Ne- 
phritis, 
The  urine  is  always  albuminous.  Urine  not  constantly  albuminous. 

Urine  usually  scanty.  Urine  usually  abundant. 

Dropsy  and  cedema  almost  always  Dropsy  seldom  or  never  present ; 

occur.  sometimes  slight  oedema. 

Hypertrophy  of  the  heart  seldom  Some  hypertrophy  of  heart,  with 

exists.  increased  arterial  tension,  almost  al- 
ways present. 
Specific   gravity   of  lu^ine   usually  Urine  generally   of  a  light  color 

higher  than  the  normal.   Urine  darker  and  low  specific  gravity, 
and  with  less  of  a  soapy  appearance 
than  in  chronic  interstidal  nephritis. 
12 


178 


PRACTICE    OF    MEDICINE. 


In  Chronic  Croupous  Nkphritis,       In     Chronic     Interstitiai.    Nb. 

piiritis, 
Uncmic  symptoms  are  met  with  in 
their  most  pronounced  form,  and  in 
severe  cases  usually  occur. 

Epistaxisand  cerebral  hemorrhages 
frequent. 

Occurs  most  frequently  after  forty. 


Unemic    symptoms    less    frequent 
than  in  chronic  interstitial  nephritis. 


Epislaxis  and  cerebral  hemorrhages 
rare. 

Occurs  most  frequently  before  the 
age  of  forty. 

Blood  corpuscles  and  connective- 
tissue  shreds  more  frequently  found 
in  chronic  croupous  nephritis. 


Casts  more  numerous  and  in  greater 
variety  than  in  chronic  interstitial 
nephritis;  waxy,  granular,  fatty,  and 
hyaline  casts  occurring. 

Epithelia  from  the  kindey  and  pus 
corpuscles  more  numerous  than  in 
interstitial  nephritis. 

Urates  and  phosphates  predomi- 
nate ;  oxalates  rare. 

Albuminous  retinitis  rare. 

Gangrenous  erysipelas  and  phleg- 
monous swellings  more  common  ;  also 
dyspepsia  and  anoemia. 

Visceral  complications,  as  pneu- 
monia, pleuritis,  pericarditis,  and 
bronchitis,  not  uncommon. 

Diarrhoea  sometimes. 

Cirrhosis  of  liver  rare. 

Atheroma  of  arteries  rare. 


Absent  in  chronic  interstitial  ne- 
phritis. 

Development  more  gradual,  the 
health  of  patient  often  less  impaired, 
and  duration  longer  than  in  chronic 
croupous  nephritis. 

Casts  rare,  the  hyaline  variety  be- 
ing most  frequently  met  with. 


Kidney  epithelia   and  pus  corpus- 
cles scanty,  and  occasionally  absent. 

Oxalate  of  lime  almost  always  oc- 
curs. 

Albuminous  retinitis  common. 


Visceral  complications  rare. 


Cirrhosis  the  most  frequent  hepatic 
lesion. 

Atheroma  common. 


Prognosis.  Pursues  a  very  chronic  course  ;  cases  recorded  under 
observation  eleven  years.  If  the  case  is  seen  in  its  incipiency,  a 
cure  is  possible,  but  as  a  rule  we  say  the  prognosis  is  unfavoiiible. 


DISEASES   OF  THE   KIDNEYS.  179 

Treatment.  To  prolong  life  is  the  great  indication,  as  the  dis- 
eased kidneys  cannot  be  restored. 

Regulated  diet  is  of  first  importance.  The  eliminating  function 
of  the  kidney  being  lessened,  the  diet  must  be  one  as  free  from  urea 
as  possible.  Milk  should  be  the  chief  and  for  long  periods  the  only 
nitrogenous  food  used ;  plain,  skimmed,  and  diluted  with  Vichy, 
ApoUinaris,  and  Seltzer  waters.  Eggs,  soft-boiled  or  poached  in  milk. 
Occasionally  chicken  broth.  The  remainder  of  the  diet  should  come 
from  the  vegetable  list.     Avoid  alcoholic  stimulants. 

A  daily  warm  or  hot  bath  is  valuable,  but  under  no  consideration 
should  cold  or  sea  bathing  be  allowed.  Warm  clothing,  and  protect- 
ing the  body  from  cold  and  damp  is  most  important. 

Rest  of  mind  and  body  as  far  as  circumstances  will  permit. 

The  bowels  should  be  kept  regular  and  soluble  with  salines  or  cas- 
cara  sagrada,  which  is  said  to  be  a  valuable  eliminator  of  urea  ;  until 
the  urine  becomes  scanty  diuretics  are  not  indicated.  Ferrum 
should  only  be  used  for  the  ansmia. 

For  the  nephritic,  cardiac,  and  vessel  changes  there  is  no  one 
remedy  comparable  with  niiroglycerinum,  or  spiritus glonoini,  in  doses 
of  nvj  (0.06  Cc),  which  equals  gr.  ^nu  (0.00065  Gm.),  repeated  three 
to  six  times  a  day.  An  excellent  combination  in  the  early  stages  of 
interstitial  nephritis  is  : 

R .     Hydrargyri  chloridi  corrosiv.,  .    .  gr.  j  .065  Gm. 

Aurii  et  sodii  chloridi, gr.  j  .065  Gm. 

Ferrireduct., gr.  xxx  2.         Gm. 

Spts.  glonoini, Tr\^xxx  2.        Cc. 

Ft  pil.  no.  xxx. 

SiG. — One  after  meals. 

Potassii  iodidum  has  been  recommended  to  prevent  or  hinder  the 
connective-tissue  growth.  If  syphilis  can  be  traced  as  the  causative 
factor,  it  should  be  given  a  trial. 

For  the  urcEuiic  symptoms  the  reader  is  referred  to  that  subject. 

For  the  gastric  symptoms  the  following  is  an  excellent  formula  : 

U .     Pepsin,  puras, gr.  xxxij  2.  Gm. 

Acidi  hydrochloric,  dil.,    .    .    .    .  f  .^  ss  15.  Cc. 

Glycerin!, f5j  30.  Cc. 

AquL^  chloroformi,     ....    ad  f^iij  90.  Cc.  M. 

SiG. — One  teaspoonful  at  meal-time,  well  diluted. 


180  PRACTICE    OF    MEDICINE. 

AMYLOID  KIDNEY. 

Synonyms.  Chronic  Bright's  disease  ;  waxy  kidney  ;  lardaceous 
kidney. 

Definition.  A  peculiar  infiltration  into,  or  a  degeneration  of,  the 
structure  of  the  kidney,  from  the  deposit  of  an  albuminoid  material, 
having  a  superficial  resemblance  to  molten  wax  or  boiled  starch.  Simi- 
lar changes  occur  in  the  liver,  spleen,  intestines,  and  other  organs. 

Causes.  The  chief  cause  is  prolonged  suppuration,  especially  of 
tha  bones  ;  coxalgia  ;  syphilis  ;  cancer  ;  phthisis. 

Pathological  Anatomy.  The  kidney  is  uniformly  enlarged. 
It  presents  a  pale,  glistening,  translucent  appearance,  and  has  a 
doughy  consistency.  On  section,  the  surface  is  homogeneous, 
anaemic,  and  whitish.  The  deposit  occurs  along  the  renal  vessels  and 
in  the  vascular  tufts  of  the  glomeruli,  progressing  until  all  parts  of  the 
organ  are  infiltrated.  When  the  organ  is  thus  infiltrated,  the  proper 
structure  undergoes  an  atrophic  degeneration,  the  result  of  pressure. 

The  reaction  with  iodine  and  sulphuric  acid  afifords  a  certain  test 
of  the  amyloid  d^Q^osxt.  Brush  over  a  section  of  the  affected  kidney 
a  solution  of  iodine  with  iodide  of  potassium  in  water,  when  a 
mahogany  color  will  be  produced,  and  if  diluted  sulphuric  acid  is  now 
added,  a  violet  or  bluish  tint  results.  A  very  pretty  reaction  is  to  take 
a  one  per  cent,  solution  of  anilin  violet,  which  strikes  a  red  or  pink 
color  with  the  amyloid  material,  while  the  unaltered  tissues  are 
stained  blue,  making  a  beautiful  contrast. 

Similar  changes  occur  in  other  organs  of  the  body.  With  the  amy- 
loid change  may  be  associated  either  parenchymatous  or  interstitial 
nephritis. 

Symptoms.  Associated  with  wasting  are  cedema  of  the  lower 
extremities  and  ascites,  with  an  increased  flow  of  uritie,  pale,  watery, 
and  of  low  specific  gravity,  containing  albumin  and  hyaline  casts, 
which  are  transparent.  If  the  amyloid  change  be  associated  with 
other  forms  of  renal  change,  the  urine  will  show  the  characteristics  of 
such  condition.  A  profuse,  watery,  and  persistent  diarr/icea  caused 
by  the  amyloid  changes  in  the  intestinal  canal. 

Diagnosis.  Differs  ixova.  parenchymatous  nephritis  in  its  clinical 
history,  and  the  fact  of  its  always  being  associated  with  a  suppurating 
disease. 

From  interstitial  nephritis,  in  its  history,  character  of  the  urine, 


DISEASES   OF  THE   KIDNEYS.  181 

absence  of  ursemia,  cardiac  hypertrophy,  changes  in  the  vessels,  and 
the  fact  of  its  association  with  suppurating  diseases  and  similar 
changes  in  other  organs. 

Prognosis.  Controlled  by  the  suppurating  disease  with  which  it 
is  associated  ;  the  termination,  when  the  amyloid  change  is  fully  de- 
veloped, is  unfavorable,  death  occurring  within  a  few  months,  or, 
under  favorable  conditions,  not  for  one  or  more  years. 

Treatment.  Sustaining  and  symptomatic  in  character.  Gener- 
ous diet  and  the  persistent  use  oi  ferriiodidunt,  alternating  with  am- 
monii  chloridum  and  oleum  morrhuce. 

If  caused  by  syphilis,  a  thorough  course  oi  potassii  iodidum,ferri 
iodidum,  and  hydrargyri  corrosivian  chloridicm,  with  oleum  morrhuce. 

If  of  syphilitic  origin,  the  plan  of  Keyes  (Dr.  E.  L.)  is  to  be  com- 
mended :  "  A  case  treated  from  the  first  should  receive  mercury 
continuously  in  small  doses,  gr.  -^  to  gr.  ^^  (0.0015-0.002  Gm.),  for 
a  period  not  less  than  two  and  a  half  years,  or,  in  any  event,  until 
at  least  six  months  have  passed  after  the  entire  disappearance  of 
the  clearly  syphilitic  symptoms." 


PYELITIS. 

Synonyms.     Suppurative  nephritis  ;  pyelo-nephritis. 

Definition.  An  acute  catarrhal  inflammation  of  the  pelvis  of  the 
kidney  ;  the  X.&cva. pyelo-nephritis  is  used  when  suppurative  inflamma- 
tion is  superadded  to  the  catarrhal  inflammation.  The  disease  is 
characterized  by  lumbar  pains,  irritability  of  the  bladder,  the  urine 
neutral  or  alkaline  in  reaction  and  milky  in  appearance;  \{ pyelo- 
nephritis occur,  symptoms  of  hectic  fever  and  exhaustion  are  added, 
the  urine  containing  pus. 

Causes.  Cold  or  exposure  ;  cystitis  ;  obstruction  of  the  ureters 
by  renal  calculi ;  pressure  from  a  tumor ;  prolonged  use  of  bromides 
and  other  irritative  drugs  ;  rheumatism  ;  sequelae  of  infectious  diseases. 

Pathological  Anatomy.  The  inflammation  is  catarrhal ;  it  is 
characterized  by  injection  of  the  mucous  membrane  of  the  pelvis  of 
the  kidney,  with  slight  extravasations  of  blood  ;  relaxation  and  soft- 
ening, shedding  of  the  epithelium,  and  the  subsequent  discharge  of 
mucus  and  pus.  If  the  morbid  condition  has  existed  for  some  time, 
the  kidneys,  one  or  both,  are  in  a  process  of  suppuration  ;  they  are 


182  PRACTICE   OF    MEDICINE. 

enlarged,  deeply  congested,  except  where  suppuration  is  proceeding, 
when  they  are  of  a  yellowish-white  color — pyclo-tiephritis.  I'us  is 
constantly  forming,  and  if  there  be  no  obstruction,  flows  away  with 
the  urine  ;  should  there  be  an  impediment  to  its  escape,  pus  accumu- 
lates in  the  pelvis  of  the  kidney,  causing  its  distention,  giving  rise 
to  the  condition  known  7i% pyclo-nephrosis.  The  pressure  caused  by 
the  obstruction  finally  leads  to  destruction  of  the  entire  organ,  a 
mere  sac,  or  renal  cyst,  remaining. 

Symptoms.  If  caused  by  cystitis,  symptoms  of  this  condition 
occur  first;  if  from  renal  calculi,  its  characteristic  symptoms  precede 
those  of  pyelitis. 

Begins  by  chilliness,  feverishness,  lumbar  pains  following  the 
course  of  the  wxtX^xs,  frequent  micturition,  the  urine  viilky  in  appear- 
ance when  voided,  acid  or  neutral  in  reaction,  and  depositing  a 
copious  sediment,  whitish  or  yellowish-white  in  color,  containing 
only  a  small  amount  of  albumin,  no  more  than  is  due  to  the/«5. 

Cases  of  pyelitis  due  to  renal  calculi  frequently  s,\\qv/  hemorrhages  ; 
the  urine  bloody  after  some  extra  exertion. 

\i pyelo-ntphriiis  ioWow,  symptoms  of  pyemia  supervene,  to  wit: 
fever,  typhoid  in  character,  low,  muttering  delirium,  subsultus  iendi- 
num,  stupor,  decline  in  strength,  and  loss  of  flesh,  with  perhaps  a 
tumor  in  the  lumbar  region. 

If  both  kidneys  are  affected,  urcemic  symptoms  are  frequent. 

Diagnosis.  From  cystitis,  by  history,  lumbar  pains,  and  acidity 
or  purulent  urine,  the  urine  in  cystitis  being  always  alkaline.  A 
microscopical  examination  of  the  urine  will  aid  the  diagnosis  very 
much. 

Perinephritis,  a  disease  of  the  loose  tissue,  around  about  the  kid- 
neys, terminating  in  abscess,  causing  lumbar  pain,  increased  by 
motion  or  pressure,  hectic  fever,  sense  of  fluctuation  over  kidneys, 
the  urine  remaining  normal. 

Prognosis.  Simple  cases,  where  no  obstruction  to  flow  of  pus, 
recover  \\\  a  week  or  ten  days.  If  obstruction  of  the  ureter,  the  prog- 
nosis is  grave.     Suppurative  cases  unfavorable. 

Treatment.  Rest  in  bed.  Milk  diet.  Free  use  of  water  to 
dilute  the  urine,  and  free  diaphoresis.  Qui7ii7ia  sulphas  to  keep  down 
temperature,  prevent  formation  of  pus,  and  maintain  the  powers  of 
hfe. 

To  change  the  character  of  the  secretion.  Prof.  Da  Costa  strongly 


DISEASES   OF   THE   KIDNEYS.  183 

recommends //;r  liquida  ;  other  remedies  are  oleum  sMitali,  copaiba, 
eucalypiol,  ierebinihina,  and  cubeba.  I  have  seen  excellent  results 
from  a  prolonged  course  of  the  Buffalo  Lithia  Springs  water  or  the 
Rockbridge  Alum  Springs  water  of  Virginia. 

For  renal  hemorrhage,  ahanen,  gr.  xx  (1.3  Gm.),  repeated  p.  r.  n., 
is  successful. 

\{ abscess  results,  aspiratioti,  quinincE  sulphas,  and  siiimdanis.  Ex- 
tirpation of  the  diseased  kidney  has  been  followed  with  fair  health. 


ACUTE   UREMIA. 

Synonyms.  Urasmic  poisoning  ;  ureemic  intoxication  ;  ursmic 
coma;  uraemic  convulsions. 

Definition.  A  group  of  nervous  phenomena,  which  occasionally 
develop  during  the  course  of  acute  or  chronic  Bright's  disease,  and 
other  maladies,  the  result  of  the  retention  or  accumulation  in  the 
blood  of  an  excrementitious  material,  supposed  to  be  urea,  the  flow 
of  urine  being  either  normal,  lessened,  or  increased. 

Causes.  Suppression  of  urine,  from  acute  or  chronic  Bright's 
disease,  probably  more  frequent  in  chronic  parenchymatous  nephritis  ; 
cystic,  tubercular,  or  cancerous  kidney  ;  the  puerperal  state;  opera- 
tions on  the  uterus  bladder,  urethra,  or  rectum. 

Symptoms.  Ursemic  intoxication  is  the  result  of  the  failure  of 
the  kidneys  to  perform  their  normal  function  of  eliminating  some  one 
or  all  of  the  poisonous  elements  of  the  urine. 

The  toxaemia  may  develop  suddenly,  by  a  convulsive  seizure  fol- 
lowed by  coma,  or  slowly  and  gradually.  Usually  the  attack  is  pre- 
ceded by  a  decrease  in  the  urinary  secretion  and  slight  or  marked 
oedema  in  various  parts  of  the  body  ;  although  it  must  be  borne  in 
mind  that  in  rare  instances,  during,  or  immediately  prior  to,  the  ap- 
pearance of  the  urEemic  phenomena,  the  normal  urinary  flow  has 
been  largely  exceeded. 

The  acute  outbreak  may  manifest  itself  in  a  variety  of  ways. 

Gastro-intestinal  variety :  The  patient  suddenly  experiences  attacks 
oi vertigo, pallor  of  face,  nausea  and  vomiting,  y!\ih.  fever,  the  tempera- 
ture varying  between  100°  and  io'^°,  pulse  tense  and  rapid,  respiration 
hurried,  and  the  urine  scanty  with  low  specific  gravity  ;  unless  symp- 
toms are  promptly  relieved,  convulsions  may  occur,  followed  by  coma 


184  PRACTICE    OF    MEDICINE. 

nnd  death,  or  drowsiness  supervenes,  followed  by  coma,  which  is  really 
nothing  but  a  profound  sleep.  Rarely  an  acute  maniacal  outbreak 
follows  the  gastro-intestinal  symptoms. 

Convulsive  variety.  Without  any  appreciable  prodromes,  epilepti- 
form convulsions,  with  or  without  loss  of  consciousness.  The  convul- 
sions may  consist  of  a  single  paroxysm,  or  a  succession  of  fits  may  fol- 
low one  another  at  intervals  of  a  few  minutes  or  several  hours,  the 
patient  in  a  condition  of  more  or  less  profound  insensibility  during 
the  intervals.  The  fits  closely  simulate  true  epilepsy.  In  this  variety 
the  temperature  is  high,  from  103°  to  106°  or  more,  the  pulse  rapid, 
with  or  without  tension,  the  respirations  quickened.  Coma  followed 
by  death  is  a  very  common  ending  of  this  variety  of  uraemia,  or 
after  a  profound  sleep  of  hours  the  patient  gradually  recovers  his 
usual  health.  Alcoholic  excesses  are  responsible  for  many  of  these 
attacks. 

Cerebral  variety,  or  urcemic  cotna.  Develops  gradually,  with  an 
increasing  drowsiness,  associated  with  headache  and  irritability  of 
temper  (mild  mania).  Nausea,  vomiting,  and  rise  of  temperature, 
often  reaching  105°,  rarely  107°,  with  rapid,  full  pulse,  or\\\&  patient 
may  fall  suddenly  into  a  condition  of  profound  coma,  the  symptoms 
closely  resembling  an  apoplectic  stroke,  excepting  the  high  tempera- 
ture. Uraemic  coma  is  always  accompanied  with  rise  of  temperature 
and  stertor.  "  The  stertor  is  peculiar  ;  it  is  not  the  '  snoring  '  of  apo- 
plexy, but  a  sharp,  hissing  sound  produced  by  the  rush  of  expired  air 
against  the  teeth  or  hard  palate."  (Loomis.)  The  respirations  are 
accelerated,  the  pulse  rapid  but  minus  tension.  This  variety  may 
suddenly  terminate  fatally  with  a  convulsion,  or  a  deepening  coma 
with  prostration  and  cold,  wet  skin,  with  oedema  of  the  lungs,  or, 
rarely,  gradual  recovery. 

Diagnosis.  Uiaemic  conditions  closely  resemble  a  number  of 
conditions  in  which  convulsions  and  coma  are  prominent  symptoms. 
Much  valuable  assistance  is  obtained  by  a  knowledge  of  the  condition 
of  the  kidneys.  Always  obtain  a  specimen  of  urine  at  once  and  sub- 
ject to  an  albumin  test  at  least. 

Another  valuable  aid  is  the  temperature  record.  I  believe  acute 
outbreaks  of  uraemia  are  always  associated  with  arise  of  temperature. 
The  temperature  is  the  result  of  the  irritation  of  the  heat-centres  and 
not  due  to  an  increased  arterial  pressure. 

Cerebral  apoplexy  may  be  mistaken  for  uraemic  coma,  or  the  re- 


DISEASES   OF  THE   KIDNEYS.  185 

verse.  The  chief  points  of  distinction  are  that  in  the  latter  the  attack 
is  usually  in  patients  suffering  from  dropsy,  and  that  the  coma  is  not 
sudden  in  its  appearance,  but  is  generally  preceded  by  other  nervous 
phenomena,  such  as  headache,  vertigo,  dimness  of  vision,  obstinate 
vomiting,  and  convulsions.  Again,  the  U7-(Emic  stertor  is  a  sharp, 
hissing  sound,  while  that  of  apoplexy  is  "  snoring."  Apoplexy  is  fol- 
lowed by  paralysis;  uremic  coma  is  not. 

An  epileptic  seizure  is  preceded  by  a  sharp  cry  and  extreme  pallor 
of  the  face,  the  countenance  being  dusky  in  uraemic  convulsions. 

Prognosis.  An  attack  of  acute  uraemia  is  always  a  very  grave 
condition.  The  prognosis  depends  upon  the  amount  of  retained 
poison,  the  length  of  time  it  has  been  retained,  and  the  condition  of 
the  organs  of  elimination. 

Treatment.  Promptness  and  thoroughness  is  the  essential  point 
in  the  treatment  of  a  uraemic  outbreak. 

For  the  gastro-intestinal  variety,  put  patient  to  bed  and  administer 
the  magnesium  sulphate  enema  given  below,  and  order  ^k'Ccl^x  caffeince 
citrata,  gr.  iij  (0.2  Gm.),  every  three  hours,  or  the  spartein  and  pilo- 
carpine mixture  mentioned  below.  As  soon  as  the  secretions  have 
been  started,  give  one  of  the  following  powders  every  two  hours  until 
a  dozen  or  more  are  used,  followed  by  Hunyadi  Janos  water: 

^.      Hydrargyri  chlor.  mitis,    .    .    .    .  gr.  X~/^  .016-.032  Gm. 

Sodii  bicarb  , gr-  ij  -130  Gm. 

Pulv.  ipecacuanhas, gi"-  3^  .o\\  Gm.    M. 

Ft.  chart.  No.  j. 

For  the  convulsive  or  cerebral  variety,  the  indications  are :  first, 
to  arrest  the  nervous  phenomena ;  secondly,  to  promote  elimination. 
Prof.  Loomis  has  succeeded  in  meeting  both  of  these  conditions  by 
hypodermic  m]&c\.\orYsoi morphince sulphas,  gr.  y(,-%-%.  (o.oi  1-0.016- 
0.032  Gm),  repeated,  if  required,  every  two  hours.  He  says  :  "  The 
most  uniform  effect  of  morphine  so  administered  is,  first,  to  arrest  mus- 
cular spasms;  second,  to  establish  profuse  diaphoresis  ;  third,  to  facili- 
tate the  action  of  cathartics  and  diuretics,  especially  the  action  of 
digitalis." 

Following  the  injection  of  morphina,  diaphoresis  should  be  pro- 
moted by  means  of  the  hot-air  bath,  or  the  hot  wet  pack,  or  the  hypo- 
dermic use  of  pilocarpijtcB  hydf-ochloras,  gr.  X2~/^~X  (0.005-0.01 1- 
0.016  Gm.),  provided  no  counter-indication  to  its  use  exists,  or  using 
at  the  same  time  frequent  doses  of  caffeines  citrata,  gr.  iij  (0.2  Gm.). 


18f)  PRACTICE    OP    MEDICINE. 

The  foUowinj^  combination  has  given  excellent  results  in  a  number 
of  cases  when  the  patient  was  able  to  swallow  : 

R.     Spartein;e  sulpliat., gT-  '^  .26501x1. 

PilocarpiiKV  hydrochlor.,    ....     Rr.  j  .065  Gm. 

Infus.  digital., f5ij  60.        Cc.  M. 

SiG. — Teaspoonful  every  half  hour,  hour,  or  two  hours  until  effect. 

Spiritusglonoini  added  to  the  above  combination  is  valuable. 
If  patient  is  unable  to  use  the  medicine  by  stomach,  the  same  drugs 
can  be  used  by  the  hypodermic  method,  using  digitalinae  cryst. : 

li.     Digitalinre  cryst., S^-  ih  .001  Gm. 

Pilocarpinre  hydrochlor.,  .    .    .    •  g^-  %  •016  Gm. 

Sparteine  sulph., gr-  K  .032  Gm. 

AqucE  deslil.,      Tt\,xv  I.         Cc.  M. 

SiG. — As  dose  p.  r.  n. 

Or— 

U  .     PilocarpincE  nitrat. gr.  ij  .13  Gm. 

Unguent,  petrolei, f.^j  30.       Gm.  M. 

SiG. — Apply  (rubbed)  bis  die  over  kidneys. 

I  have  never  observed  the  alarming  symptoms  of  depression  men- 
tioned by  some  observers  from  the  careful  use  of  pilocarpus. 

The  production  of  free  diaphoresis  alone  must  not  mislead,  for 
unless  the  sweat  contains  urea  or  its  products  it  is  only  depressing, 
and  the  clinical  fact  is  that  in  uraemia  the  eliminating  function  of 
the  skin  as  well  as  of  the  kidney  is  in  abeyance. 

The  convulsions  are  rapidly  controlled  by  inhalations  of  chloroform 
(although  the  after  symptoms  are  badly  influenced  by  the  drug),  or 
the  internal  or  rectal  administration  of  full  doses  oi chloral,  or  by  a 
free  venesection.  Indeed,  venesection  is  too  much  neglected  in  condi- 
tions of  coma  and  uraemic  convulsions.  It  not  infrequently  happens 
that  upon  opening  a  vessel  the  blood  does  not  flow,  or  but  a  few  drops 
slowly  flow  from  the  wound.  If  this  obtains  it  is  almost  immediately 
changed  by  a  hypodermic  injection  oi  amyl  nitrite,  n\,v  (0.3  Cc.)  with 
spiritiis  ammonicE  aromatictis,  TT\,xv  (l  Cc). 

Diuresis  is  promoted  by  infusiim  digitalis,  dry  or  wet  cupping, 
poultices  over  the  loins,  and  hot  compresses  of  infusum  digitalis  over 
abdomen,  pilocarpus  rubbed  over  the  kidneys,  or  caffcina:  citrata,  or 
spartei7tcB  sulphas,  or  spiritus  glonoini.  The  injection  of  the  nor- 
mal salt  solution,  3j  :  Oj  (4  Gm.  :   473  Cc),  into  the  bowel   every 


DISEASES   OF  THE   KIDNEYS.  187 

hour  or  two,  and  by  hypodermoclysisinto  the  loose  connective  tissue, 
promotes  diaphoresis  and  diuresis.  Excellent  results  have  been  ob- 
tained in  uraemia  with  scanty  urinary  secretion  and  in  other  condi- 
tions with  scanty  urine  with  diureiin  (a  mixture  of  salicylate  of  soda 
and  theobromin)  in  gr.  xx-xxx  (1.3-2  Gm.)  in  an  ounce  of  water 
every  two  or  four  hours. 

Catharsis  is  best  promoted  by  elateriujn,  gr.  xs-J  (0.005-0.008  Gm.), 
or  an  Epsom  salts  enema  : 

■R .     Magnesii  sulph.,     ..=    ....  _^ij  60.  Gm. 

Glycerini, ^j  30.  Cc. 

Aquffibul., giv  I20.  Cc.  M. 

As  enema. 

The  febrile  reaction  does  not  call  for  antipyretics.  It  is  one  of 
the  nervous  phenomena  of  ursemia,  and  is  controlled  by  the  means 
employed  to  eliminate  the  poison. 

If  symptoms  of  collapse  develop,  with  cold,  clammy  skin,  feeble, 
rapid  pulse,  and  superficial  respirations,  at  once  administer  atropincz 
sulphas,  gr.  ^  (o.ooi  Gm.),  repeat  p.  r.  n.,  2.VidL  strychnines  suiph., 
S""- •5j~tV  (0.002-0.004  Gm.),  repeated  p.  r.  n.,  with  rf\\]  (0.12  Cc.) 
spiritus  glonoini,  and  bathe  surface  with  hot  water  and  alcohol. 

Of  late,  sodii  benzoas,  3j-ij  (4-8  Gm.)  during  the  twenty-four  hours, 
has  been  lauded  as  almost  a  specific  in  urasmic  intoxication.  Under 
the  action  of  this  remedy  the  paroxysms  lessen  in  severity,  the  inter- 
vals grow  longer,  and  the  convulsions  after  a  time  cease  entirely. 
Profound  sleep  is  induced  by  it,  and  during  this  the  cerebral  functions 
are  restored.  When  albuminuria  exists,  a  marked  diminution  occurs 
in  the  quantity  present,  or  the  albumin  disappears  entirely. 

Milk,  in  as  large  quantities,  diluted  as  can  be  borne,  should  be  the 
diet.  The  attack  broken,  the  treatment  resolves  itself  into  that  of  the 
nephritic  affection  causing  it. 


RENAL  CALCULI. 

Synonyms.     Nephro-lithiasis  ;  gravel ;  renal  colic. 

Definition.  Renal  calculi  are  concretions  formed  by  the  precipi- 
tation of  certain  substances  from  the  urine,  around  some  body  or  sub- 
stance acting  as  a  nucleus. 


188  PRACTICE    OF    MEDICINE. 

Their  presence  may  not  be  recognized  until  one  or  more  attempts  to 
pass  along  the  ureters,  when  an  attack  of  renal  colic  results;  or,  by 
irritation, /j(f////j  is  produced;  or,  more  rarely,  they  are  voided  by 
the  urine  without  exciting  any  symptoms. 

By  oravfl is  meant  very  small  concretions  (sand),  which  are  often 
passed  in  the  urine  in  large  numbers. 

Causes.  Occur  at  all  ages  ;  frequent  at  forty  to  fifty  years  of  age. 
Males  are  more  liable  than  females.  A  special  liability  seems  to 
exist  in  some  families,  but  the  precise  etiology  of  calculi  is  not  yet 
determined. 

Varieties,  i.  Un'c  acid,  as  calculi  and  gravel,  and  especially 
associated  with  the  gouty  diathesis. 

2.  Urates,  chiefly  urate  of  ammonium  ;  nearly  always  in  childhood, 

3.  Oxalate  of  lime  ox  mulberry  calculus ;  characterized  by  hardness, 
roughness,  and  very  dark  color. 

4.  Phosphatic  calculi  form  as  frequently  in  the  bladder  as  in  the 
kidney,  and  present  a  chalky  or  earthy  appearance. 

5.  Alternating  calculi,  consisting  of  alternate  layers  of  two  or  more 
primary  deposits. 

Anatomical  Characters.  In  structure,  a  urinary  calculus 
usually  consists  of  a  central  nucleus,  surrounded  by  the  body,  and 
outside  of  all  there  may  be  a  phosphatic  crust.  The  nucleus  may  or 
may  not  be  of  the  same  material  as  the  rest  of  the  stone,  sometimes 
being  a  foreign  body,  mucus,  or  blood. 

A  section  generally  shows  a  stratified  arrangement,  or  it  may  be 
partly  or  completely  radiated. 

Symptoms.  Many  individuals  have  renal  calculi  and  have  no 
suspicion  of  their  presence  until  an  attack  of  renal  colic  occurs. 

The  following  signs  indicate  a  renal  stone  :  pain  in  back,  princi- 
pally in  either  dorso-lumbar  region  with  tenderness;  renal  hemor- 
rhage (haematuria),  always  a  valuable  symptom  ;  slight  albuminuria, 
but  no  pus,  with  a  few  hyaline  casts — these  are  long  and  narrow; 
urine  of  high  specific  gravity  is  an  important  clinical  symptom  ;  in- 
flammation terminating  in  abscess,  pyelitis  ox  pyelo-nephritis,  cystitis, 
or  renal  colic. 

The  symptoms  of  retial  colic  begin  abruptly,  by  severe,  agonizing, 
pain  in  the  lumbar  region  following  the  ureters  into  the  corresponding 
groin  and  thigh.  Pain  and  retraction  of  the  corresponding  testicle  ; 
also  of  glans  penis.     Face  pale  ?iX\d  features  pinched,  the  surface  cold 


DISEASES   OF  THE  KIDNEYS.  189 

and  damp.  Irritability  of  the  bladder,  the  urine  passing  in  drops 
containing  some  blood.  So  severe  is  the  pain  at  times  that  the 
patient  may  faint  or  pass  into  unconsciousness,  or  have  a  general 
convulsion.     If  both  ureters  are  obstructed,  urcE7nic  syjnpioms  occur. 

The  paroxysm  usually  terminates  suddenly  after  some  minutes  or 
hours,  the  stone  escaping  into  the  bladder. 

Diagnosis.  Not  always  easy,  but  the  following  are  symptoms  of 
renal  stone ;  pain  and  tenderness  in  back,  persistent  haematuria, 
albuminuria,  hyalin  casts,  and  high  specific  gravity  of  urine,  and 
attacks  of  renal  colic.  The  Roentgen  ray  is  the  hope  for  correct 
diagnosis. 

Prognosis.  Renal  calculus  is  attended  with  many  dangers.  It 
may  produce  extensive  disorganization  of  the  kidneys,  or  its  passage 
along  the  ureter  may  prove  fatal.  If  the  stone  be  very  large,  or  if 
more  than  one,  the  prognosis  is  graver.  Calculus  is  a  disease  very 
apt  to  recur.  Renal  sand  {gravel)  and  small  concretions  may,  after 
more  or  less  delay,  be  voided  with  the  urine. 

Treatment.  An  attack  of  renal  colic  is  best  relieved  by  a 
hypodermic  injection  of  morphines  sulphas  and  atropines  sulphas, 
and  a  warm  bath  or  a  suppository  of  ext.  opii,  gr.  j  (0.065  Gm.),  ext. 
belladon?icB  alco.,  gr.  ss  (0.032  Gm.),  repeated  if  needed. 

For  attacks  oi  gravel,  liquor potassii  citratis,  f^ss  (15  Cc),  every 
two  hours,  and,  if  much  vesical  irritability,  adding  tinctura  opii 
camphorata  f^ss-j  (2-4  Cc). 

For  renal  hemorrhage.  Prof.  Bartholow  reports  success  with 

R .     Extracti  ergotse  fluidi, 

Tincture  kramerise, aaf3ij  60.  Cc.  M. 

SiG. — One  teaspoonful  every  two  or  more  hours. 

I  have  always  successfully  controlled  renal  hemorrhages  with 
twenty-grain  (1.3  Gm.)  doses  of  alumen,  repeated  p.  r.  n. 

For  uric  acid  calculi,  as  a  solvent,  Buffalo  Lithia  Springs  water  or 
the  Rockbridge  Alum  Springs  water  of  Virginia,  or  potassii  tartra- 
borates,  "obtained  by  heating  together  four  parts  of  cream  of  tartar, 
one  part  of  boracic  acid,  and  ten  parts  of  water.  A  scruple  may  be 
given  three  or  four  times  a  day,  in  water,  largely  diluted." 

I  have  met  with  entire  success  in  four  cases  of  renal  calculi  by  the 
prolonged  use  oi  piperazine  gr.  v  (0.32  Gm.),  three  times  a  day  in 
several  ounces  of  water,  with  a  non-nitrogenized  diet.     Potter  sug- 


100  PRACTICE   OF    MEDICINE. 

gests  the  following  in  the  uric  acid  diathesis  with  a  tendency  to  for- 
mation of  renal  calculi : 

K.     Magnesii  carbonat., 3J  4-  Gm. 

Acid,  citrici ^\]  8.  Gm. 

Sodii  borat., q  ij  8.  Gm. 

Ar|ure  bullientis, 3^''j  240.  Cc.  M. 

SiG. — Tablespoonful  three  times  daily,  diluted. 

For  phosphatic  calculi,  as  a  solvent,  ammonii  benzoas,  well  diluted 
and  long  continued  is  highly  commended. 


CYSTITIS. 

Synonym.     Catarrh  of  the  bladder. 

Definition.  An  inflammation  of  the  mucous  membrane  lining 
the  urinary  bladder,  acute  or  chronic  in  its  course,  and  of  either  a 
catarrhal,  croupous,  or  diphtheritic  character ;  characterized  by  rigors, 
moderate  fever,  hypogastric  pain,  frequent  but  scanty  micturition,  and 
severe  vesical  tenesmus,  the  urine  containing  pus  (pyuria). 

Causes.  Acute  variety  :  long  retention  of  urine;  foreign  bodies 
in  the  bladder;  pyelitis;  urethritis;  blows  over  the  pubes;  myelitisi 
and  secondary  to  fevers  or  diphtheria.  Chronic  variety:  following 
the  acute  variety  ;  retention  the  result  of  enlarged  prostate  or  a 
urethral  stricture  ;  calculi ;  gout ;  chronic  Bright's  disease. 

Pathological  Anatomy.  \n  acute  catarrhal  cystitis  Xh^rt  first 
ensues  hyperemia  of  the  mucous  membrane  of  the  entire  or  a  por- 
tion of  the  bladder,  manifested  by  redness,  swelling,  and  oedema; 
followed  by  an  increased  secretion  of  the  small  glands  at  the  base  of 
the  bladder,  and  an  increased  growth  and  consequent  desquamation 
of  the  vesical  epithelium,  together  with  a  copious  generation  of  young 
cells ;  if  the  hyperemia  be  decided,  rupture  of  the  capillaries  and 
extravasation  of  blood  occur. 

If  the  inflammation  be  intense,  suppuration  of  the  submucous  con- 
nective tissue  may  result,  and  ulceration  of  the  mucous  membrane 
permit  the  submucous  abscesses  to  empty  into  the  bladder. 

If  the  inflammation  be  of  a  croupous  or  diphtheritic  character,  the 
morbid  anatomy  does  not  differ  from  the  same  variety  of  inflamma- 
tions in  other  mucous  membranes. 


DISEASES   OF   THE   KIDNEYS.  191. 

In  chronic  cystitis  "the  mucous  membrane  is  thick,  blue-gray  in 
color,  and  very  tough.  Muco-pus  and  viscid  mucus  are  formed  in 
large  quantities  upon  its  surface.  The  muscular  wall  of  the  bladder 
may  sometimes  be  half  an  inch  thick,  and  the  fasciculi  give  a  ribbed 
appearance  to  the  internal  surface,  called  the  '  columnar  bladder.' 
The  hypertrophy  of  chronic  cystitis  may  be  eccentric  or  concentric. 
In  some  cases  diverticuli  are  formed,  in  whose  walls  are  dilated  and 
tortuous  veins.  In  nearly  all  cases  bacteria  are  found  in  abundance." 
(Loomis.) 

Symptoms.  Acute  cystitis  :  The  onset  is  usually  abrupt,  by  rigors, 
slight  y^T/^r,  loss  of  appetite,  sleeplessness,  a  feeling  of  depression, 
frequent  micturition,  though  the  urine  is  only  voided  drop  by  drop, 
and  its  passage  followed  by  distressing  vesical  tenesmus,  the  result  of 
spasm  of  the  bladder ;  pain  over  the  pubis  and  in  the  iliac  regions, 
of  a  dull  character,  at  times  becoming  sharp  and  agonizing.  Burn- 
ing along  the  urethra  adds  to  the  distress  of  the  patient. 

The  urine  is  cloudy,  of  an  alkaline  reaction,  and  at  times  is  fetid, 
the  microscope  showing  epitheliu7n,  pus,  and  red  blood  corpttscles  and 
various  forms  of  bacteria. 

Chronic  cystitis  :  The  onset  is  gradual  and  insidious,  and  is  excited 
by  some  obstacle  to  the  evacuation  of  the  urine,  such  as  stricture, 
the  presence  of  a  stone  in  the  bladder,  or  enlargement  of  the  prostate 
gland.  There  are  present  dull  pain,  frequent  h\it  scanty  micturition. 
The  urine  is  alkaliite,  containing  large  amounts  of  muco-pus  or  pus ; 
on  standing  it  deposits  a  thick,  glairy,  viscid  sediment,  in  which, 
under  the  microscope,  triple  phosphates  and  large  pus  corpuscles, 
extremely  regular  both  in  contents  and  in  shape,  may  be  detected. 

Although  the  quantity  of  urine  voided  by  the  patient  is  small,  yet 
if  immediately  after  micturition  the  catheter  is  used,  several  ounces 
oi  fetid,  cloudy,  alkaline  urine  may  be  removed. 

Patients  with  chronic  cystitis  usually  present  decided  constitutional 
debility  and  mental  depression. 

Severe  local  pain,  emaciation,  and  occasional  bloody  urine  indicate 
ulceration  of  the  vesical  mucous  membrane. 

Diagnosis.  Pyelitis  has  lumbar  pains  following  the  course  of  the 
ureters,  frequent  micturition  without  the  severe  vesical  tenesmus  ;  the 
urine,  although  cloudy,  has  an  acid  or  neutral  reaction. 

Prognosis.  The  acute  variety  is,  as  a  rule,  good,  being  controlled 
by  the  cause. 


192  PRACTICK    OF    MEDICINE. 

The  chronic  variety  continues  for  years,  and  after  hypertrophy  of 
the  bladder  is  incurable. 

Treatment.  Rest  in  bed  is  invaluable.  The  diet  must  be  restricted, 
all  highly-seasoned  articles  being  particularly  interdicted  ;  milk  is  the 
most  suitable  article. 

Warm  applications  over  the  pubic  region  are  of  benefit,  and  leech- 
ing and  cupping  over  the  bladder  are  of  service. 

The  urine  should  be  well  diluted  by  large  drauglits  of  pure  water, 

and  particularly  the  alkaline  mineral  waters,  to  wit :  Farmville  liihia, 

Buffalo  lithia,  Rockbridge  alum,  or  Vichy  waters.     The  following 

formulae  are  of  decided  benefit : 

» 

R .     Acidi  benzoici, 

Sodii  borat., aa  jij  aa      8.     Gm. 

Infusi  Imchu,  vel 

Infusi  uva;  ursi, f5^'j  "So.     Cc.  M. 

SiG. — Tablespoonful  every  two  hours,  well  diluted. 

Or— 

R.     Tinct.  hy  ■scyami fi5vj  24.    Cc. 

Tinct.  opii  camph., fS^'j  24.     Cc. 

Potassii  broniidi, 

Sodii  bicarb.,      aa        ►^viij      aa         lo. 5  Gm. 

Liq.  potassii  citrat.,    ...      q.  s.  fjviij      q.  s.  240.     Cc.  M. 

SiG. — Tablespoonful  every  two  or  three  hours,  in  water. 

A  valuable  prescription  is — 

R.     Ext.  picbi  fld. f^^j  30.  Cc. 

Potassii  nitrat., zj  4.  Gm. 

Elix.  simplicis, f  5  i'j  9°-  Cc.  M. 

SiG. — One  teaspoonful  every  two  hours,  well  diluted. 

Or— 

R.     Liq.  potassse  (B.  Ph.) {-i^X]  8.     Cc. 

01.  santal.  flav., f  i:;  ij  8.     Cc. 

Aq.  cinnamom., adf^viij  240.     Cc.  M. 

Sic. — Tablespoonful  three  times  daily,  diluted.  (Saundby.) 

For  alkaline  urine  from  any  cause,  amtnottii  beiizoas,  gr.  xx  (1.3 
Gm.)  in  water,  or  liquor  potassii  citratis,  seems  like  a  specific. 

For  the  pain  and  tenesmus  relief  is  afforded  by  a  suppository  of 
extracium  opii  and  exiractum  belladonna ,xt.\>^-3X^^  as  needed.  Hot 
compresses  over  bladder  and  hot  enemata  often  relieve  the  pain  of 
cystitis. 


DISEASES   OF  THE   KIDNEYS.  193 

The  vesical  tenestnus  is  often  benefited  by  extractum  catinabis 
indica  fliddum,  Tr\,xv-xxx  (1-2  Cc),  every  three  or  four  hours. 

Chronic  cystHis.  The  bladder  should  be  completely  emptied  with 
the  catheter  several  times  in  the  twenty-four  hours. 

The  use  of  eucalyptol,  gtt.  x-xv  (0.6-1  Cc),  every  four  hours, 
well  diluted,  or  a  good  preparation  of  tar,  or  extractum  grindelice 
fluidum,  Ti^xx-fjj  (1.3-4  Cc),  three  or  four  times  daily,  or  oleum 
santali,  gtt.  v-x  (0.3-0.6  Cc),  in  emulsion  or  capsule  after  meals, 
are  valuable  remedies.  Acidu?n  boricuni,  gr.  v-xv  (0.3-1  Gm.), 
internally,  has  removed  pus  from  the  urine  in  chronic  cystitis. 
Washing  out  the  bladder  with  the  following  mixture  is  of  decided 
benefit : 

R .     Sodiiborat., 5j  30.     Gm. 

Glycerin!, f,^ij  60.     Cc. 

Aquae, f  Jij  60.     Cc. 

SiG. — One  to  two  tablespoonfuls  added  to  warm  water  and  injected  into  the 
bladder  once  or  twice  daily. 

The  diet  should  be  nutritious  and  without  spices  of  any  kind.  The 
free  use  of  the  alkaline  mineral  waters  is  of  value. 


MOVABLE  KIDNEY. 

Synonyms.     Floating  kidney  ;  wandering  kidney  ;  nephroptosis. 

Definition.  A  condition  of  the  kidney,  either  congenital  or 
acquired,  in  which  the  tissues  around  about  the  organ  are  so  lax  and 
the  renal  vessels  so  elongated  as  to  permit  the  kidney  to  be  moved  in 
certain  directions,  causing  a  movable  tumor  in  the  abdomen. 

Causes.  The  kidney  is  normally  held  in  position  by  the  layer  of 
peritoneum  which  is  attached  to  the  anterior  surface  of  its  adipose 
capsule.  In  movable  kidney  the  adipose  tissue,  in  which  the  normal 
kidney  is  imbedded,  partly  or  wholly  disappears. 

The  renal  vessels  are  in  many  cases  abnormally  long.  Relaxation 
of  the  abdominal  walls  from  pregnancy  or  other  causes.  The  use  of 
tight  corsets  or  girdles  about  the  waist ;  violence ;  increased  weight 
of  the  organ  from  disease ;  the  pressure  of  tumors  growing  in  the 
neighborhood  of  the  kidney  ;  the  traction  of  herniee. 

The  condition  may  be  congenital  or  acquired,  more  frequently  the 
latter.     It  is  far  more  frequent  in  women  than  in  men. 
13 


194  PRACTICE    OF    MF.DICINE. 

Symptoms.  Floating  kidney  may,  and  often  does,  exist  without 
any  noticeable  symptoms,  the  condition  being  unknown  until  acci- 
dentally discovered  by  the  physician  while  making  a  physical  exami- 
nation of  the  abdomen. 

As  a  rule,  however,  patients  experience  a  heavy,  dragging  pain  in 
the  abdomen,  aggravated  when  walking  or  standing.  There  are 
also  present  gastro-intestinal  symptoms,  more  or  less  constant,  with 
melancholia,  aggravated  by  the  mental  anxiety  the  presence  of  a 
iionor'xn  the  abdomen  causes  the  patient,  in  spite  of  the  assurances 
of  the  physician  that  it  is  not  a  cancer.  ^ 

At  times,  from  some  unknown  or  unrecognized  cause,  the  movable 
kidney  swells  and  becomes  very  sensitive  to  the  touch,  and  migrates 
a  considerable  distance  from  its  normal  position.  Such  an  occurrence 
aggravates  all  the  former  symptoms  mentioned.  The  condition  has 
been  ascribed  to  a  twisting  of  the  ureter  and  consequent  retention  of 
the  urine  in  the  pelvis  of  the  kidney,  or  to  localized  peritonitis,  or  to 
a  partial  strangulation  of  the  kidney  from  compression  or  twisting  of 
its  blood-vessels. 

Hysterical  (?)  symptoms  are  frequently  observed  in  women  suffering 
from  wandering  kidney. 

Diagnosis.  The  possibility  of  dislocation  of  the  kidney  is  to  be 
recollected  in  determining  the  nature  of  obscure  tumors  within  the 
abdomen. 

The  late  Prof.  Austin  Flint  based  the  recognition  of  this  variety  of 
abdominal  tumor  on  the  following  diagnostic  points:  "It  is  situated 
in  the  hypochondriac  region.  It  has  the  size  and  shape  of  the  normal 
kidney,  and  this  may  be  determinable  by  palpation,  which  is  most 
advantageously  employed  by  placing  one  hand  over  the  lumbar  region 
and  the  other  in  front  on  the  abdominal  walls,  and  then  making 
counter-pressure  from  one  hand  to  the  other.  It  is  generally  movable, 
and  in  some  cases  the  organ  can  be  restored  to  its  proper  situation." 

Other  tumors  are  to  be  excluded  by  the  absence  of  their  diagnostic 
characters. 

Prognosis.  It  is  a  rare  occurrence  to  have  a  fatal  termination 
from  movable  kidney  per  se. 

Treatment.  Symptomatic.  It  is  said  that  some  of  the  incon- 
venience and  sometimes  suffering  attending  movable  kidney  may  be 
lessened  by  means  of  an  abdominal  bandage,  belt,  or  supporter. 

If  attacks  of  pain  and  swelling  occur,  the  patient  should  be  placed 


DISEASES   OF   THE   BLOOD.  195 

in  bed,  have  hot  applications  over  the  abdomen,  and  the  use  of  opiates 
and  attempts  at  replacing  the  organ. 

Extirpation  of  a  movable  kidney  has  been  successfully  performed 
a  number  of  times. 

Nephrorrhaphy,  an  operation  for  fixation  of  the  kidney  by  means 
of  sutures,  has  been  devised. 


DISEASES  OF  THE  BLOOD. 


ANEMIA. 

Synonym.    Spansemia. 

Definition.  A  deficiency  of  red  corpuscles  in  the  blood,  or  of  its 
more  important  constituents,  such  as  albumin  and  haemoglobin,  or  a 
reduction  in  the  amount  of  blood  as  a  whole  ;  characterized  by  pallor 
and  general  weakness. 

Oligamia  is  a  general  lessened  amount  of  the  blood.  Ischcemia  is 
a  localized  anaemia. 

Causes.  Predisposing:  Sex;  females,  pregnancy  and  meno- 
pause ;  heredity ;  pronounced  anaemia  without  apparent  cause 
is  strongly  suspicious  of  concealed  tuberculosis. 

ExcHi7ig :  Deficient  food,  air,  or  sunshine  ;  excessive  work  ;  mental 
worry  ;  mental  shock ;  prolonged  and  frequent  nocturnal  emissions ; 
excessive  nursing;  chronic  intestinal  catarrh;  Bright's  disease; 
malaria;  syphilis;  cancer. 

Pathological  Anatomy.  Post-mortem,  the  tissues  are  thin, 
shrunken,  and  bloodless.  If  the  anaemia  has  been  of  long  duration, 
patches  of  fatty  change  are  seen  in  the  various  organs.  The  blood 
has  a  brighter  color,  the  result  of  diminution  in  the  number  of  red 
corpuscles  and  the  quantity  of  the  haemoglobin  ;  it  is  thinner  than 
normal,  and  coagulates  slowly  and  imperfectly,  from  diminution  of  the 
fibrino-plastic  constituent. 

In  health  the  blood  of  an  adult  contains  about  five  million  red  cor- 
puscles to  the  cubic  millimeter  (the  female  adult  about  half  a  million 
less).  The  white  cells,  in  health,  average  about  ten  thousand  to  the 
cubic  millimeter. 


196  PRACTICE   OF    MEDICINE. 

Symptoms.  Pallor,  gums,  tongue,  ear,  and  conjunctivae  pale. 
AfuSiitlar  wi-aktie-ss,  inability  for  exertion.  Deficient  appetite  and 
impaired  digestion,  attacks  of  vomiting  the  result  of  anaemia  of  the 
medulla  oblongata.  Quickened  respiration,  irritable  temper,  vertigo 
in  the  erect  position,  attacks  of  swooning,  /lysteria,  and  rarely  epilepsy. 
Irritable  heart,  with  soft  systolic  basic  murmurs.  Nocturnal  emissions 
in  male  and  deficient  menses  in  female.  Marasmus  in  children. 
More  or  less  general  a'dema  of  the  eyelids  and  ankles.  Long  con- 
tinued, symptoms  of  fatty  changes  in  various  orgjyis  or  gastrjc  ulcer 
result. 

Diagnosis.  The  symptoms  of  anaemia  are  so  characteristic  that 
an  error  is  impossible;  the  cause  of  it,  however,  may  be  hidden. 

Prognosis.  Favorable  if  treated  early.  If  protracted,  results  in 
more  or  less  general  symptoms  of  fatty  degenerations  or  ulcer  of  the 
stomach. 

Treatment.  Remove  the  cause.  Easily  assimilated,  blood-pro- 
ducing diet.  Fresh  air,  sunlight,  and  exercise  short  of  fatigue,  The 
anaemic  patient  should  spend  several  hours  in  bed  during  the  day- 
time.    Purgatives,  with  stomachic  tonics,  to  promote  digestion. 

For  the  anaemia  proper,  ferrum  in  some  form  is  the  most  valuable 
remedy,  always  remembering  that  it  is  not  assimilated  if  the  intestines 
and  liver  be  torpid.  Ferri  carbonatis,  gr.  ij-v  (0.13-0.32  Gm.),  is  an 
excellent  form  of  iron  too  little  employed. 

The  following  alterative  tonic,  known  as  Smith's  (Dr.  A.  H.)  "  four 
chlorides,"  is  frequently  of  value  : 

R.     Hydrargyri  chloridi  corrosivi,  .    .    gr.  j-ij  .065-.  13  Gm. 

Liq.  arsenici  chloridi, f^j  4.  Cc. 

Tinct.  ferri  chloridi, 

Acid!  hydrochlorici  dil.,  .    .    .aaf^iv     aa  15.  Cc. 

Syrupi, f^'^  'S-  Cc. 

AqucE, adf^vj  180.  Cc.  M. 

SiG. — One  dessertspoonful  in  a  wineglassful  of  water  after  each  meal. 

Cases  of  anaemia  with  weak  stomach  can  take  the  following  "  iron 
lemonade  "  with  ease  : 

R.     Tinct.  ferri  chloridi, f^ij  8.  Cc. 

Acid,  phosphor,  dil., fgij  8.  Cc. 

Syr.  limonis, f.^ss  15.  Cc. 

Aquce, f  5  ij  60.  Cc.                         M. 

SiG. — One  teaspoonful,  well  diluted. 


DISEASES   OF  THE   BLOOD.  197 


CHLOROSIS. 


Synonyms.     Essential  ansemia  ;  green  sickness. 

Definition.  A  pronounced  anaemia  met  with  chiefly  in  young  girls 
about  the  age  of  puberty,  characterized  by  diminution  in  the  percent- 
age of  hsemoglobin. 

Causes.  The  true  cause  unknown.  A  disease  for  the  most  part 
of  puberty.  Most  frequently  seen  in  the  ill-fed,  overworked  town 
girls,  who  are  deprived  of  sunshine  and  fresh  air.  Heredity  is  sup- 
posed to  play  a  part  in  its  causation.  Hammond  maintains  "  that  it 
is  an  affection  of  the  nervous  system,  the  blood  changes  being 
secondary." 

Pathological  Anatomy.  Death  from  chlorosis  is  such  a  rare 
occurrence  that  little  data  is  known.  The  number  of  red  corpuscles 
is  nearly  normal,  but  there  is  marked  decrease  in  the  haemoglobin, 
sometimes  as  low  as  twenty  per  cent,  of  the  normal,  or  even  less. 
Virchow  pointed  out  the  hypoplasia  of  the  arterial  system,  many 
arteries  being  congenitally  small.  The  body  is  usually  well  nour- 
ished and  the  subcutaneous  fat  well  distributed.  There  is  pallor  of 
the  organs  and  muscular  system.  The  spleen,  lymphatics,  and  the 
marrow  of  the  bones  are  not  affected. 

Symptoms.  The  condition  is  associated  with  disorders  of  men- 
struation. The  young  girl  experiences  a  change  of  disposition,  becom- 
ing morose  and  despondent,  rarely  hysterical  ox  melancholiac. 

"As  respects  the  actual  condition  of  the  sexual  organs,  there  are 
two  forms  of  derangement  which  happen  in  chlorosis  :  there  are  the 
amenorrhceic  form  and  the  menorrhagic  form." 

After  an  attack  of  menorrhagia  or  after  the  failure  of  the  flow  to 
appear,  the  changes  occur.  The  complexion  changes,  blondes  be- 
coming pallid,  waxy,  and  puffy  without  cedema  ;  brunettes  becoming 
muddy  and  grayish  in  color,  with  bluish-black  rings  under  the  eyes. 
Weariness  and  fatigue  upon  the  least  exertion ;  the  heart  irritable, 
with  shortness  of  breath,  pulse  full  but  soft,  and  at  times  pulsations  in 
the  peripheral  veins.  The  appetite  is  vitiated,  the  digestion  imper- 
fect; and  attacks  of  gastralgia  are  frequent. 

A  not  infrequent  complication  is  gastric  ulcer.  Phthisis  develops 
in  those  having  the  slightest  predisposition. 

Examination  of  the  blood  shows  a  relative  decrease  in  quality  and 


198  PRACTICE    OF    MKDICINE. 

quantity  of  the  haemoglobin,  resulting  in  the  blood  being  paler  than 
normal.  The  red  corpuscles  are  also  lighter  in  color  and  show  less 
tendency  to  form  rouleaux ;  their  character  also  changes,  not  all 
being  of  uniform  size,  some  normal,  others  small  (microcytes),  others 
unusually  large  (macrocytes),  others  irregularly  shaped  (poikilocytes). 
The  number  may  be  normal,  5,000,000  to  the  cubic  millimeter,  or  the 
number  is  occasionally  increased,  but  it  is  usually  lessened,  there 
being  as  few  as  3,000,000  or  2,000,000.  ^ 

The  white  corpuscles  are  usually  normal  in  nuniber,  but  in  some 
instances  their  number  is  increased  (leucocytosis).  Rarely  granular 
bodies  are  found  in  the  blood  which  are  generally  regarded  as  the 
products  of  the  degeneration  of  the  white  blood  corpuscles. 

Diagnosis.  The  disease  is  usually  recognized  at  once  by  the 
color  of  the  patient,  whence  its  common  name,  green  sickness. 

The  circulatory  symptoms  and  slight  oedema  may  be  mistaken  for 
cardiac  or  nephritic  diseases. 

Prognosis.  The  liability  to  complications  and  also  to  relapses, 
and  the  lack  of  knowledge  of  the  true  cause,  make  the  prognosis 
always  uncertain. 

Treatment.  Three  indications  to  be  met  in  the  treatment  of 
chlorosis  :  plenty  of  food,  fresh  air,  and  ferrum.  The  form  of  iron  is 
immaterial.  The  tinctura  fcrri  chloridi'xs  the  preparation  usually 
prescribed. 

J.  W.  England,  Ph.G.,  has  proposed  the  following  formula  for  an 
iron  pill  that  has  been  successfully  used  at  the  Philadelphia  Hospital: 

R.      Massre  ferri  c.nrb. , gr.  xlviij  3.       Gm. 

Potassii  sulph., gr.  xxxiv  2.       Gm. 

Potassii  carb. , gr.  v^  .33  Gm. 

Pulv.  aUliere, gr.  iss  .02  Gm. 

Pulv.  acacix, q.  s.  q.  s.  M. 

Ft.  pil.  No.  xvj,  and  inclose  in  gelatin  capsules. 

The  following  is  Blaud's  formula,  so  highly  lauded  by  Nie- 
meyer  : 

li.     Pulv.  ferri  sulph., 

Potasbii  carbonat.  purse,     .    .      aafjss  aa    15.   Gm. 

Tragacantlije,      q.  s.  M. 

Ft.  pil.  No.  xcvj. 

SiG. — One  to  three  or  four  pills  three  times  daily. 


DISEASES   OF  THE   BLOOD.  199 

In  some  instances y>rr«;;z  alone  does  not  seem  to  answer;  in  such 
cases  the  addition  of  arsenicum  is  valuable  ;  a  good  combination  is — 

K-      Ferri  arseniatis, gr.  y^-g^  .005-. oil  Gm. 

Ext.  nucis  vomicse, gr.  \--\  .011-.016  Gm.     M. 

Ft.  pil.  No.  j. 
SiG. — After  meals. 

Or— 

R .     Liq.  arsenici  chloridi, fj'j  8.  Cc. 

Tinct.  ferri  chloridi,   .    .    .    ■    .    .  f^^vij  28.  Cc. 

Glycerini, f^j  30.  Cc. 

Elix.  aurantii,      .    .    .    .    q.  s.  adf^iij  90.  Cc.                M. 
SiG. — One  teaspoonful  after  meals,  in  water. 


PROGRESSIVE  PERNICIOUS  ANEMIA. 

S37Tionyins.  Idiopathic  anaemia  ;  ansematosis  ;  essential  anaemia ; 
anaemia  of  fatty  heart. 

Definition.  A  pernicious,  progressive  form  of  anaemia,  of  un- 
known cause,  usually  resisting  all  treatment,  and  toward  its  termina- 
tion associated  with  fever. 

Causes.  The  underlying  cause  of  idiopathic  anaemia  is  not 
known.  Among  the  exciting  causes  may  be  mentioned  pregnancy, 
syphilis,  and  great  worry.  It  is  thought  that  it  is  probably  the  result 
of  a  toxin. 

Pathological  Anatomy.  The  blood  is  scanty  and  pale,  with 
diminished  red  corpuscles  and  haemoglobin,  showing  a  very  feeble 
tendency  to  coagulate.     There  is  no  increase  in  the  white  corpuscles. 

The  marrow  in  adult  bones  becomes  foetal,  red,  and  adenoid,  and 
contains  microcytes;  several  other  changes  have  occurred  second- 
arily in  the  marrow. 

Secondary  to  the  anaemia,  the  heart,  larger  arteries,  and  certain 
capillary  tracts  exhibit  circumscribed  or  diffused  fatty  degeneration. 

The  liver,  spleen,  kidneys,  and  stomach  are  decidedly  anemic, 
causing  fatty  changes  in  those  organs.  The  skin  may  contain 
petechiae  of  a  purplish  or  brownish  tint,  and  internal  hemorrhages 
are  not  infrequent ;  retinal  hemorrhage  is  rarely  wanting. 

There  is  not  much  emaciation,  though  the  pallor  is  pronounced. 


200  PRACTICE    OF    MEDICINE. 

Symptoms.  It  begins  insidiously  with  increasing  languor  and 
pallor,  tiie  muscular  weakness  compelling  the  patient  to  take  his  bed. 
Cardiac  palpitation,  clyspncea,  attacks  of  syncope,  cedevta,  and  swell- 
ing about  the  ankles,  petechial  spots  scattered  irregularly  over  the 
surface;  tenderness  over  the  sternum  and  other  superficial  bones  is  a 
frequent  symptom. 

The  appetite  is  wanting,  and  nausea  and  vopniting  occur,  associated 
with  marked  dyspepsia  and  persistent  diarrhoea.  As  the  disease 
progresses  a  remittent  form  oi  fever  develops,  the  temperature  fre- 
quently showing  io2°-io4°  F. 

Disorders  of  vision  are  the  result  of  the  retinal  hemorrhage.  The 
cardiac  sounds  are  feeble,  and  associated  with  soft  basic  or  anaemic 
murmurs. 

The  blood  shows  under  the  microscope  the  changes  described  in 
chlorosis,  save  the  red  corpuscles  may  be  reduced  to  as  few  as  500,- 
000,  or  even  less,  to  the  cubic  millimetre. 

"  In  addition,  the  following  points  of  great  diagnostic  importance 
are  to  be  noted. 

"  First,  the  individual  red  corpuscles  are  richer  than  normal  in 
haemoglobin. 

"  Second,  many  red  corpuscles  are  larger  than  normal  (megalo- 
cytes). 

"  Third,  the  red  corpuscles  are  deformed,  some  being  ovoid,  others 
irregular  in  shape  from  projections  and  constrictions  on  their  surfaces 
(poikilocytes). 

"  Fourth,  there  are  present  microcytes  or  red  blood-cells,  which 
are  smaller  than  normal. 

"  Fifth,  nucleated  red  blood-cells  (normoblasts). 

"  Sixth,  quite  constantly,  there  are  other  large  cells  like  the  megalo- 
cytes,  named  megaloblasts,  which  have  a  pale  staining  nucleus." 
(Hare.) 

Diagnosis.  Progressive  pernicious  anaemia  is  distinguished  from 
simple  anaemia  and  chlorosis  by  the  greater  severity  of  the  former. 
From  leucocythemia  by  the  normal-sized  spleen  and  liver,  and  the 
absence  of  (leucocytosis)  increase  in  the  white  corpuscles. 

Prognosis.  Unfavorable  as  a  rule,  although  recoveries  occur,  but 
relapses  frequent. 

Treatment.  The  employment  of  arsenicum,  either  alone  or  com- 
bined with  ferrum,  has  considerably  changed  the  prognosis  of  per- 


DISEASES   OF  THE   BLOOD.  201 

nicious  anaemia.     The  arsenicum  must  be  pushed  to  the  extreme  point 
of  toleration  and  continued  for  a  long  time. 

Rest  in  bed  and  a  liberal  nutritious  diet  are  also  essential. 


LEUCOCYTHEMIA. 

Synonyms.  Leucaemia ;  white  cell  blood ;  white  blood  ;  anaemia 
splenica. 

Definition.  A  condition  in  which  there  is  an  enormous  increase 
in  the  number  of  white  blood  corpuscles,  with  enlargement  of  the 
lymphatic  glands,  spleen,  and  often  of  the  bone  marrow — viz. : 
splenic,  ly??tphaiic,  or  myelogenic,  and  is  characterized  by  symptoms 
oi  pronounced  anaemia. 

Causes.     The  real  cause  and  nature  of  the  affection  is  unknown. 

Pathological  Anatomy.  The  spleen  is  increased  in  size,  den- 
sity, and  firmness  ;  the  lymphatic  glands  all  over  the  body  also 
enlarge,  but  are  soft  to  the  touch,  often  fluctuating ;  the  marrow  of  the 
bones  changes  from  its  normal  rose  color  to  that  of  a  greenish-yellow  ; 
the  liver  also  enlarges  enormously.  The  blood  is  paler  than  normal, 
its  specific  gravity  reduced  from  1.055  to  1.040  or  lower,  andthe«/-^z/<? 
corpuscles  increased  (leucocytosis)  in  number  and  in  size,  the  red 
corpuscles  being  lessened  in  number  and  size. 

Symptoms.  The  onset  is  insidious,  and  the  early  progress  of  the 
disease  is  identical  with  that  of  simple  anaemia,  accompanied  by 
swelling  of  the  abdomefi  and  a  feeling  oi  fullness  and  pain  in  the 
splenic  region,  due  to  the  enlargement  of  that  organ. 

In  the  lymphatic  variety,  enlargement  of  the  glands  in  the  groin, 
neck,  and  axillary  region  are  associated  with  "C^ix^  great  pallor. 

In  the  myelogenic  variety,  the  bones,  more  particularly  the  ribs 
and  sternum,  are  tender  on  pressure,  the  patient  developing  a  waxy 
appearance. 

In  each  variety  the  appetite  is  poor,  the  digestion  feeble,  the  bowels 
loose,  the  patient  easily  fatigued,  with  cardiac  palpitation  and  dysp- 
noea, with  oedema  of  the  eyelids  and  ankles.  The  urine  is  scanty 
and  of  high  specific  gravity — i. 020-1. 030.  Fatal  hemorrhages  occur 
near  the  termination  of  the  disease. 

The  blood  is  pale  and  watery.  The  white  blood  corpuscles  are 
enormously  increased  in  number.      The  average  number  of  white 


202  PRACTICE    OF    MEDICINE. 

corpuscles  to  the  cubic  millimetre  normally  is  about  10,000.  Cases 
are  recorded  in  which  the  number  of  white  blood  corpuscles  has 
equaled  or  even  exceeded  the  red  blood  corpuscles.  The  size  ofthe 
white  cor]niscles  varies  in  different  cases  and  also  in  the  same  case. 

Diag'nosis.  This  should  cause  but^  little  trouble  if  enlarged 
spleen,  lymphatic  glands,  and  tender  bones  are  associated  with  great 
pallor,  and  the  characteristic  appearance  of  the  blood  as  demonstrated 
by  a  "puncture  of  the  finger  of  the  patient,  and  receiving  the  blood 
on  a  piece  of  white  linen  or  a  lawn  handkerchief,  and  placing  by  the 
side  of  it  a  similar  stain  of  blood  from  a  healthy  subject.  The  full 
color  of  the  latter  contrasts  strikingly  with  the  stain  of  the  former, 
which  is  hardly  of  a  blood  color  and  translucent." 

A  microscopical  examination  and  blood  count  at  once  determines 
the  presence  of  the  disease. 

Acute  phthisis  associated  with  enlarged  bronchial  and  cervical 
glands  shows  the  leucocytosis  of  leucocythemia,  but  has  the  lung 
changes  and  hectic  symptoms  in  addition. 

Prognosis.  Unfavorable.  The  average  duration  is  between  two 
and  three  years.  Cases  of  what  are  termed  "  acute  leukaemia," 
proving  fatal  in  a  few  months,  occur. 

Treatment.  Symptomatic.  A  combination  of  the  following 
remedies,  with  generous  diet,  fresh  air,  sunshine,  pleasant  surround- 
ings, oleum  morrJiucp,  and  the  hypophospJiitcs,  have  at  times  seemed 
of  temporary  value — to  wit :  quinines  sulphas,  arsenicuin ,  ferrum ,  and 
ergoia. 

Dr.  Da  Costa  has  had  some  success  by  the  inhalation  of  oxygen, 
twenty  to  one  hundred  liters  during  the  day. 

HODGKIN'S  DISEASE. 

Synonyms.  Pseudo-leukemia;  Pseudo-leucocythemia;  lym- 
phatic anaemia;  lymphadenoma. 

Definition.  An  affection  characterized  by  hypertrophy  of  the 
lymphatic  glands  in  various  parts  of  the  body,  associated  with  marked 
anaemia. 

Cause.     Unknown. 

Pathological  Anatomy.  A  hyperplasia  of  the  lymph  glands 
interfering  more  or  less  wiih  their  functions.  The  enlargement  may 
be  confined  to  one  isolated  gland,  or  a  number  may  be  affected  in 


DISEASES   OF  THE   BLOOD.  203 

different  portions  of  the  body,  or  a  number  in  one  location  may  be 
simultaneously  affected,  causing  a  tumor  varying  in  size  from  an  egg 
to  an  orange  or  even  larger. 

The  spleen  and  liver  are  involved  in  two-thirds  of  the  cases. 
"The  marrow  of  the  long  bones  may  be  converted  into  a  rich 
lymphoid  tissue."     (Osier.) 

The  red  blood  corpuscles  are  decreased  in  number  and  altered  in 
size  and  shape ;  the  white  blood  corpuscles  are  often  increased  in 
number. 

Symptoms.  A  slowly  developing  ansemia  with  isolated  or  dif- 
fused enlargement  of  the  lymphatic  glands.  As  the  condition 
develops,  fever  of  a  remittent  character  occurs,  with  feeble  cardiac 
action  and  shortness  of  breath.  Hemorrhages  may  occur.  The 
patient  grows  progressively  worse  with  all  the  associated  symptoms  of 
deficient  blood,  death  occurring  by  asthenia. 

Diagnosis.  A  study  of  the  clinical  history  will  prevent  error,  as 
tubercular  or  scrofulous  glands  are  accompanied  with  tubercular 
changes  in  the  lungs,  and  do  not  present  the  same  blood-changes  as 
Hodgkin's  disease. 

Prognosis.  Unfavorable.  The  progress  may  be  slow,  but  it  is 
none  the  less  toward  a  fatal  termination. 

Treatm.ent.  The  indications  are  all  toward  a  building  up  of  the 
blood.  Amongst  the  remedies  recommended  are  arsenictwi,  phos- 
phorus, ferruvi,  quinince  sulphas,  and  oleum  morrhuce.  Excision  of 
the  glands  in  the  early  stage  may  be  practiced. 

ADDISON'S  DISEASE. 

Synonym.     Melasma  supra-renalis. 

Definition.  "The  bronzed-skin  disease."  Thus  defined  by 
Averbeck :  "A  well-marked  constitutional  disease,  exhibiting  itself 
locally  as  a  chronic  inflammation  of  the  supra-renal  capsules,  but  in 
its  essence  consisting  in  a  peculiar  ansmic  condition,  always  tending 
toward  death,  which  is  characterized  by  intense  development  of  pig- 
ment in  the  cells  of  the  rete  malpighii  and  in  the  epithelium  of  the 
mucous  membrane  of  the  mouth." 

Causes.  Obscure.  Tubercle,  scrofula,  and  syphilis  have  each 
been  given  as  the  cause. 

Pathological  Anatomy,     A  low  form  of  inflammation,  termi- 


204  PRACTICE    OF    MEDICINE. 

nating  in  degeneration  of  the  supra-renal  capsule.  The  blood  is 
deficient  in  fibrin  and  red  corpuscles,  with  a  slight  increase  of  the 
white  corpuscles.  Fatty  degeneration  of  the  heart  and  vessels  has 
been  observed  in  some  cases. 

"  The  most  striking  change  during  life — the  abnormal  pigmentation 
— is  due  to  the  deposition  of  granular  pigment  in  the  cells  of  the  rete 
malpighii,  in  the  papillary  portion  of  the  cutis,  and  even  in  the  con- 
nective tissue  corpuscles.  No  change  occurs  in  the  proper  structure 
of  the  skin.  Similar  pigment  deposits  occur  in  the  mucous  membrane 
of  the  mouth,  especially  along  the  edges  of  the  teeth." 

"  The  disease  of  the  supra-renal  capsules  excites  an  irritation  of 
the  vaso-motor  system — the  trophic  system — which  leads  to  the  pig- 
mentation." 

Symptoms.  The  onset  of  the  disease  is  insidious,  with  a  feeling 
of  e.xtreme  languor,  7nusciilar  fatigue,  asthenia,  indigestion,  anorexia, 
dyspjicea,  cardiac  palpitation,  vertigo,  tnelajicholia,  and  excessive 
drowsiness. 

The  surface  is  first  pale,  then  changes  to  a  hue  like  that  of  vielan- 
CBinia,  changing  to  icteroid,  finally  resembling  the  color  of  a  mulatto, 
and  then  to  a  lustreless  bronze.  These  changes  also  occur  on  the 
mucous  membrane  of  the  lips,  tongue,  gums,  and  mouth. 

Prognosis.     An  incurable  disease.     Duration,  a  year  or  two. 

Treatment.     Symptomatic. 

HEMOPHILIA. 

Synonyms.     Hemorrhagic  diathesis  ;  "bleeder's  disease." 

Definition.  A  congenital  condition  characterized  by  a  tendency 
to  uncontrollable  hemorrhages,  with  or  without  abrasions. 

Cause.     Hereditary. 

Symptoms.  The  bleeding  appears  about  the  period  of  first 
dentition,  and  consists  of  spontaneous  hetnorrhages  from  the  mucous 
membrane  of  the  nose,  mouth,  lungs,  stomach,  intestines,  and  genito- 
urinary passages,  or  \xi  perfect  cases  hemorrhages  occur  directly  from 
the  fingers,  toes,  lobes  of  the  ears,  back  of  the  hands  or  arms,  without 
any  apparent  change  in  the  skin,  and  continue  in  spite  of  the  most 
powerful  means,  for  days  or  weeks.  Traumatic  hemorrhages  occur 
if  an  injury  of  any  kind  is  sustained  about  the  period  of  the  develop- 
ment of  the  bleeding. 


DISEASES   OF  THE   BLOOD.  205 

Epistaxis  is  the  most  common  form  of  all  those  named. 

Attacks  of  arthritis  with  fever  occur  with  haemophilia,  resembling 
acute  rheumatism. 

As  a  result  of  the  great  loss  of  blood,  the  individual  suffers  from  all 
the  symptoms  of  profound  aneemia. 

Diagnosis.  It  is  impossible  to  confound  the  "bleeder's  disease" 
with  any  other  affection. 

Prog'nosis.  Death  is  the  usual  termination  within  a  few  weeks 
from  the  time  of  its  development,  which  may  not  be  until  adult  life. 

Treatment.  Entirely  symptomatic.  It  is  claimed  that  " potassii 
chloras — an  ounce  of  a  saturated  solution  three  times  a  day — com- 
bined with  tinctura  ferri  chloridi,''  will  eradicate  the  constitutional 
tendency. 

SCORBUTUS. 

Synonyms.     Scurvy  ;  scorbutic  purpura. 

Definition.  A  peculiar  condition  of  malnutrition  or  anaemia, 
gradually  developing  upon  a  dietary  deficient  in  fresh  vegetable 
material;  characterized  by  decided  anaemia,  debility,  mental  lethargy, 
petechiae,  and  a  swollen  and  spongy  state  of  the  gums,  with  a  ten- 
dency to  bleed  upon  the  slightest  irritation. 

Causes.  The  disease  only  occurs  when  fresh  vegetable  nutriment 
or  some  appropriate  substitute  has  been  for  a  time  partially  or  com- 
pletely withheld.  It  is  held  that  the  diet  alone  is  not  sufficient  to 
cause  the  disease;  the  mental  factor  of  depression  of  spirits,  or  in 
some  cases  home-sickness  (nostalgia),  must  be  associated. 

It  is  sometimes  classed  as  an  infectious  disease,  due  to  a  peculiar 
germ,  a  view  which  is  gaining  ground. 

Pathological  Anatomy.  An  undetermined  derangement  in 
the  composition  of  the  blood,  with  diminished  proportion  of  the  pot- 
ash salts.  Spleen  enlarged.  The  tissues  are  wasted  and  present 
extravasations,  due  to  either  one  of  or  the  combined  presence  of  the 
following  conditions,  to  wit:  liquid  condition  of  the  blood,  allowing 
it  to  escape  from  the  vessels,  alterations  in  the  walls  of  the  vessels,  or 
a  vaso- motor  paralysis. 

Symptoms.  General  weakness,  lassitude,  indisposition  to  either 
mental  or  physical  exertion.  The  skin  is  dry,  rough,  and  of  a  muddy 
pallor,  the  face  pale  and  bloated.     Sweiimg  and  sponginess  of  the 


206  PRACTICE    OF    MEDICINE. 

gums,  with  great  tendency  to  bleed  and  an  exceedingly  offensive 
breath.  Looseness  of  the  teeth,  hemorrhages  from  mucous  surfaces, 
and  extrai'asations  of  b/ood  Ww-hm  and  beneath  the  skin.  The  Zips 
are  pale,  which  is  in  striking  contrast  to  the  redness  of  the  gums  ; 
the  eyes  are  sunken  and  surrounded  by  dark  blue  circles. 

Hemorrhages  occur  from  the  stomach,  moulh,  bronchial  tubes, 
intestinal  canal,  and  vagina.  The  skin  is  dry  and  rough,  resembling 
that  of  a  plucked  fowl.   OEdema  of  the  face  and  ankles  not  infrequent. 

Depression  of  the  spirits  is  characteristic.  Palpitation  and  dyspnoea 
on  exertion.     Urine  high-colored,  speedily  becoming  fetid. 

The  patient  usually  longs  iox  fresh  vegetables  a.x\d  fruits. 

Complications.  Dysentery.  Scorbutic  dysentery  is  a  frequent 
complication.     It  may  co-exist  with  typhoid  and  typhus  fever. 

Prognosis.     Favorable,  if  early  and  properly  treated. 

Treatment.  The  chief  indication  is  the  assimilation  of  the  ali- 
mentary principles  needed  for  the  healthy  constitution  of  the  blood 
and  the  invigoration  of  the  system. 

The  juice  of  lemons,  oranges,  and  other  fruits;  it  is  wonderful  what 
improvement  will  follow  the  use  of  two  or  three  lemons  daily.  Anti- 
scorbutic vegetables,  to  wit :  raw  cabbage,  cresses,  and  raw  potatoes, 
sauer  kraut,  in  conjunction  with  meats,  milk,  and  farinaceous  food. 

Improve  the  appetite  and  digestion  by  the  use  of  strychnina  sulphas, 
quinincE  sulphas,  mineral  acids,  and  bitter  infusions.  Potassii  chloras, 
locally,  will  relieve  the  oral  symptoms. 


PURPURA. 

Synonyms.  Haemorrhoea  petechialis ;  Morbus  maculosus  Werl- 
hofii. 

Definition.  An  acute  disease,  characterized  by  purplish  discol- 
oraiions  of  the  skin,  the  result  of  hemorrhages  into  the  upper  layers 
of  the  cutis  and  beneath  the  epidermis.  When  the  purpuric  spots  are 
tiny,  like  a  pin-point,  they  are  termed  petechiae ;  when  larger  in  size, 
they  are  termed  ecchymoses. 

Varieties.  Purpura  simplex  ;  purpura  hcemorrhagica  ;  purpura 
urticans  ;  peliosis  rheumatica. 

Causes.  Not  properly  understood  ;  a  special  germ  supposed  to  be 
the  cause.     It  may  occur  at  any  age,  but  is  especially  frequent  in 


DISEASES   OF  THE   BLOOD.  207 

children  and  elderly  people.  Its  occurrence  after  the  ingestion  of 
certain  articles  of  diet  has  been  observed. 

Symptoms.  Purpura  sifnplex  is  the  mildest  form  of  the  affection, 
and  is  characterized  by  the  sudden  appearance  of  stnall,  bright  red 
spots — a  cutaneous  hemorrhage — most  commonly  on  the  legs  coming 
in  crops,  associated  with  slight  lassitude,  mild  febrile  reaction,  and 
aching  pains  in  the  limbs.  The  hue  of  the  spots  rapidly  fades  to  a 
purplish  color  and  slowly  disappear.     Relapses  are  common. 

Purpura  hcEinorrhagica  has,  in  addition  to  the  eruption  of  purpura 
simplex, — the  cutaneous  hemorrhage, — a  flow  of  blood  from  the  free 
surface  of  mucous  membranes.  The  most  common  hemorrhage  is 
epistaxis,  slight  or  profuse.  Other  hemorrhages  are  hcematemesis, 
melcena,  hcematuria,  hemoptysis,  menorrhagia,  and  also  into  the  sub- 
stance of  the  mucous  membranes  of  the  palate,  cheek,  and  gums. 
This  variety  is  associated  with  great  debility  and  depression,  moderate 
fever,  and  disorders  of  digestion.  Marked  anamia  results  from  the 
hemorrhages. 

Purpura  urticans  is  a  combination  of  urticaria  and  purpura  sim- 
plex. It  is  characterized  by  rounded  and  reddish  elevations  of  the 
cuticle,  resembling  wheals,  but  which  are  not  accompanied,  like  the 
wheals  of  urticaria,  by  any  sensation  of  itching  or  tingling.  They 
are  usually  situated  on  the  legs,  thighs,  breast,  and  arms,  and  are  inter- 
spersed with  petechias.  They  gradually  form  and  subside  within 
twenty-four  or  thirty-six  hours.     Relapses  are  frequent. 

This  variety  is  also  associated  with  malaise,  moderate  fever,  and 
pains  in  the  limbs. 

Peliosis  rheumaiica  (Schonlein's  disease)  is  characterized  by  mul- 
tiple arthritis  and  z.  purpuric  eruption  ;  frequently  the  arthritic  symp- 
toms are  associated  with  urticaria  or  with  erythema  exudativum. 
CEdema  is  often  marked,  as  in  the  fever,  sore-throat,  and  general  con- 
stitutional symptoms.  The  eruption  is  sometimes  of  vesicles — pem.- 
ph  igoid  purpura . 

Diagnosis.  The  purpuric  eruption  in  each  variety  of  the  affection 
is  so  characteristic  that  an  error  seems  impossible. 

Prognosis.  Purpura  simplex  and  purpura  urticans  are  favorable, 
but  relapses  are  very  frequent.  Purpura  haemorrhagica  is  always  a 
grave  disease,  often  proving  fatal  from  exhaustion,  or,  more  rarely, 
from  cerebral  or  pulmonary  hemorrhage.  Peliosis  rheumatica  is  often 
a  severe  affection,  but  recovery  is  the  rule. 


208  PRACTICE    OF    MEDICINE. 

Treatment.  Rest  and  a  concentrated  nutritious  diet,  and  the 
moderate  use  of  stimulants  and  tonics.  ^Irsenicuin  in  large  doses  is 
often  valuable,  using  liquor potassii  arsenilis,  to  combat  the  resulting 
anaemia. 

The  internal  use  of  oleum  terebinthina  is  one  of  the  most  reliable 
remedies  for  many  forms  of  the  disease,  but  not  when  hemorrhages 
occur  from  the  stomach  or  kidneys.  The  following  is  an  eligible 
formula: 

R.     Ol.  terebinthinre, fgij  8.  Cc. 

Ol.  amygdahTG  express., f^j  30.  Cc. 

Tinct.  opii  deodorat. , fS^s  2.  Cc. 

Mucil.  acacic-c, f?j  30.  Cc. 

Aq.  lauio-cerasi, adf5iij  ad  90.  Cc.  M. 

SiG. — One  tablespoonful  every  three  or  four  hours,  diluted. 

Among  the  other  numerous  remedies  suggested,  the  most  reliable 
have  been  aciduin  sulphuricum  dilutum  and  tifictura  ferri  chloridi. 
Good  results  have  followed  acidutn  carbolicum,  Tt\^  ij-iij  (0.13-0.2  Cc.) 
every  three  hours,  in  cases  seen  by  the  author,  and  a  particularly 
persistent  case  was  cured  by  full  doses  of  potassii  iodidmn.  Dr. 
Da  Costa,  for  hemorrhages,  strongly  recommends  extractum  ergotae 
fluidum,  f3ss-f3j  (2-4  Cc.)  every  two  hours;  or  acidum  sulphuricum 
dilutum,  n\^x-xx  (0.6-1.3  Cc.)  every  few  hours. 

"  If  hemorrhages  that  are  threatened  come  on,  with  a  strong  pulse, 
flushed  face,  headache,  and  excitement,  digitalis,  quinina,  ?inA  ergota 
are  the  appropriate  medicaments."     (Bartholow.) 

Argenti  nitras,  gr.  -^^-]i  (0.005-0.016  Gm.),  three  or  four  times 
daily,  is  of  value  in  purpura  hsemorrhagica.  Argentum  is  said  to  have 
a  specific  influence  on  the  capillary  circulation  by  its  impression  on 
the  vasomotor  nerves. 

Locally,  to  arrest  bleeding,  astringents  and  either  hot  or  cold  water 
or  ice. 


ACUTE   GENERAL   DISEASES.  209 


ACUTE   GENERAL   DISEASES. 


PAROTIDITIS. 

Synonyms. — Parotitis  ;  mumps. 

Definition.  An  acute,  specific,  infectious  inflammation  of  one  or 
both  parotid  and  other  salivary  glands  and  the  surrounding  connec- 
tive tissue,  with  a  very  strong  tendency  to  migrate  into  the  mammas 
or  testes  ;  characterized  by  pain,  swelling,  and  disordered  function  of 
the  glands. 

Causes.  A  specific  poison.  Contagious.  Occurs  in  epidemics, 
•Uthough  isolated  cases  are  seen.  Males  more  liable  than  female£. 
The  most  common  ages  between  five  years  and  puberty.  As  a  rule 
it  occurs  but  once  in  the  same  individual. 

Th.e  period  of  incubation  is  from  two  to  three  weeks. 

Pathological  Anatomy.  There  is  inflammation  of  one  or  both 
parotid  glands,  and  in  severe  epidemics  the  cellular  tissue  pervading 
the  gland  is  involved. 

The  catarrhal  inflammation  begins  in  the  gland  ducts  and  rapidly 
extends  to  the  gland  proper.  There  is  congestion,  swelling,  and  an 
infiltration  of  serous  fluid,  with  more  or  less  infiltration  of  the  adja- 
cent tissues.  The  swelling  may  suddenly  reach  an  enormous  size 
and  as  suddenly  decline,  the  gland  returning  to  its  normal  condition, 
or,  rarely,  an  abscess  results,  with  partial  or  complete  destruction  of 
the  gland.  Occasionally  the  submaxillary  gland  is  involved,  also  the 
mammae  and  testes. 

Metastatic  parotiditis  occurs  secondary  to  severe  blood-poisoning, 
as  in  pyaemia,  typhoid  or  typhus  fevers,  or  diphtheria.  The  usual 
termination  of  secondary  parotiditis  is  by  suppuration  and  destruction 
of  gland  structure. 

Symptoms.  The  onset  is  rather  sudden,  by  malaise,  chill,  fever, 
ioi°-i03°  F.,  quick  pulse,  headache,  dry  skin,  scanty  tirine,  followed 
within  a  day  or  two  by  stiffness  at  the  angles  of  the  jaw,  swelling  of 
the  parotid  z.nd  other  salivary  glands, /a/«  increased  by  moving  the 
jaws,  with  general  cedema  of  the  affected  side  of  the  face,  at  times  the 
14 


210  PRACTICE    OF    MEDICINE, 

skin  being  reddened.  Salivation  is  frequent,  and  occasionally  deaf- 
ness occurs. 

The  swelling  and  other  glandular  symptoms  subside  about  the 
sixth  or  seventh  day,  to  be  followed  by  restoration  to  health,  or,  what 
is  more  common,  the  involvement  of  the  opposite  gland. 

At  any  time  during  the  disease  metastasis  to  the  fnamvicr,  ovaries, 
or  t£stes\%  apt  to  occur,  when  the  symptoms  peculiar  to  such  affections 
will  be  added.  It  has  been  noted  that  a  continuance  of  the  tempera- 
ture after  the  decline  of  the  parotid  symptoms  has  begun  usually  is 
significant  of  metastasis.  It  is  claimed  that  the  involvement  of  other 
organs  during  the  course  of  mumps  is  not  an  example  of  metastasis, 
but  is  a  true  transfer  of  the  disease. 

Diagnosis.     An  error  seems  impossible. 

Prognosis.  Simple  mumps,  favorable;  the  chief  danger  being 
from  the  altered  function  of  the  mammae,  ovary,  or  testes  after 
metastasis. 

Treatment.  The  disease  being  self-limited,  the  indications  are 
entirely  symptomatic,  with  attention  to  the  secretions,  although  ex- 
tractum  pilocarpi  fiuidum,  li^x-xxx  (0.6-2  Cc),  repeated,  has  been 
used  with  varying  success  as  a  specific. 

Locally,  either  cold  or  warmth  to  the  affected  gland,  whichever  is 
most  agreeable,  or  equal  parts  oi  ungucntum  belladonnce  et  hydrargyn. 

If  the  swelling  shows  a  tendency  to  linger,  use  small  blisters  over 
the  part  and  administer  potassii  iodidum ;  if  suppuration  occur, 
evacuate  pus,  apply  poultices,  and  administer  quinince  sulphas. 

If  orchitis  occur,  the  use  of  the  belladontia  and  mercurial  ointment 
or  the  ice  iag  to  the  inflamed  testicle,  and  the  internal  use  of  tinctura 
pulsatillcB,  n\,iij-v  (0.2-0.3  Cc.)  every  hour  or  two,  ox  potassii  iodidum. 


DIPHTHERIA. 

Synonyms.  Putrid  sore  throat ;  malignant  ulcerous  sore  throat; 
malignant  quinsy;  membranous  angina. 

Definition.  An  acute,  specific,  constitutional  disease;  both  epi- 
demic and  contagious,  beginning  by  an  affection  of  the  throat,  char- 
acterized by  a  local  exudation  and  glandular  enlargements ;  attended 
with  fever,  great  prostration  of  the  vital  powers,  and  albuminuria,  and 
often  having  for  its  sequelae  various  paralyses. 


ACUTE  GENERAL   DISEASES.  211 

Causes.  A  s/>eczyic£-erm,  the  Klehs-hoeffiQrha.c'illus.  The  bacillus 
in  its  growth  produces  a  potent  toxic  substance, — a  toxalbumin, — the 
absorption  of  which  produces  the  disease,  and  not  the  organism  itself. 
The  diphtheria  bacillus  is  associated  with  other  pathogenic  bacteria, 
the  most  active  of  which  is  the  streptococcus  pyogenes.  It  is  pre- 
eminently a  disease  of  childhood.  It  is  apt  to  recur  in  those  who 
have  once  been  affected.  All  conditions  of  bad  hygiene  increase 
its  virulence  and  diffusion,  although  the  chief  cause  of  its  spread  is 
contagion.  Nasal,  pharyngeal,  and  laryngeal  catarrh  are  the  kind 
of  soil  promoting  the  growth  of  the  bacillus  and  its  toxin. 

The  poison  exists  in  the  exudation  and  secretions  of  the  fauces  and 
saliva,  and  floats  in  the  atmosphere  at  a  considerable  distance  from 
the  patient.  The  virus  adheres  to  the  clothing,  the  bedding,  the  fur- 
niture, and  the  room  which  the  patient  occupied. 

The  period  of  incubation  is  from  three  to  five  days. 

Pathological  Anatomy.  The  diphtheritic  inflammation  differs 
from  either  the  croupous  or  catarrhal  form,  in  that  the  exudation 
is  not  only  upon,  but  also  within,  the  substance  of  the  mucous  mem-. 
brane. 

At  first  there  is  redness,  which  may  begin  in  any  part  of  the  throat, 
associated  with  swelling  and  an  increased  secretion  of  viscus  mucus. 
The  redness  spreads  over  the  entire  mucous  surface,  when  the  exuda- 
tion makes  its  appearance,  at  first  giving  the  affected  mucous  mem- 
brane a  glazed  appearance,  which  is  very  characteristic.  The  deposit 
may  commence  from  one  or  several  points,  such  as  one  tonsil,  the 
soft  palate,  or  the  back  of  the  fauces,  which,  however,  speedily  extend 
and  coalesce,  forming  extensive  patches,  or  cover  uniformly  the  entire 
surface. 

The  patches  are  of  variable  thickness,  which  is  increased  by  suc- 
cessive layers  being  formed  underneath. 

The  color  is  usually  gray,  white,  or  slightly  yellow,  but  may  be 
brownish  or  blackish,  the  consistence  ranging  from  "  cream  to  wash 
leather." 

On  removing  the  membrane,  which  is  accomplished  with  more  or 
less  difficulty,  a  raw  bleeding  surface  is  exposed,  and  at  times  an 
ulcer,  which  is  speedily  covered  with  a  fresh  deposit. 

If  the  exudation  separate  itself,  it  is  either  not  renewed  at  all  or 
only  in  thinner  films. 

The  exudation   or  membrane,  examined   by  the  microscope,  is 


1212  PRACTICE    OF    MEDICINE. 

composed  of  fibrin,  pus  corpuscles,  epithelial  granular  cells,  and  the 
Klebs-Loeffler  bacillus  and  other  pathogenic  bacteria. 

If  the  larynx,  trachea,  or  nasal  mucous  membranes  participate  in 
the  disease,  the  crottpous  and  not  the  diphtheritic  form  of  inflamma- 
tion occurs. 

The  lyjiiphatic  glands  of  the  neck,  whose  vessels  originate  in  the 
faucial  tissues,  are  enlarged  and  inflamed,  and  contain  large  numbers 
of  bacteria,  probably  originating  as  the  result  of  decomposition. 

The  muscular  tissue  of  the  heart  becomes  soft,  is  easily  torn,  and 
its  fibrillae  are  far  advanced  in  granular  degeneration.  Ulcerative 
endocarditis  has  been  frequently  observed.  The  kidneys  undergo  a 
granular  degeneration  in  severe  attacks.  The  blood  undergoes  altera* 
tion,  being  bl  ick  and  fluid. 

Symptoms,  Following  the  law  oi  contagious  diseases,  the  symp- 
toms vary  in  intensity  in  different  cases,  the  prominent  symptoms 
being  often  disproportionate  to  the  gravity  of  the  attack. 

The  invasion  may  be  fnild,  with  rigors  succeeded  by  moderate 
fever,  headache,  languor,  loss  of  appetite,  stiffness  of  the  neck,  tender- 
7iess  about  the  angles  of  the  jaw,  or  slight  soreness  of  the  throat. 

In  other  cases  the  invasiofi  is  more  abrupt  and  severe,  with  chilli- 
ness followed  by  gxtAi  febrile  reaction,  103°  to  105°  ¥.,pain  in  the  ear, 
aching  of  the  limbs,  loss  of  strength,  painful  deglutition,  and  swelling 
of  the  neck,  compelling  the  patient  to  take  to  bed  from  the  onset. 

The  appetite  is  poor,  the  tongue  slightly  coated,  sometimes  more 
or  less  exudation  appearing  upon  it,  the  bowels  either  regular  or 
slightly  relaxed.  The  pulse,  at  first  full  and  strong,  soon  becomes 
either  rapid  or  slow,  but  compressible.  The  urine  is  scanty,  high- 
colored,  and  contains  albianin. 

The  local  symptoms  in  the  majority  of  cases  are  associated  with 
the  throat.  The  patient  often  complains  of  a  frequent  and  persistent 
desire  to  hawk,  in  order  to  clear  the  throat.  On  inspection,  the  fauces 
are  seen  red  and  swollen  and  more  or  less  covered  with  a  film  of 
diphtheritic  exudation,  giving  a  glazed  appearance,  soon  followed  by 
the  dirty-white  membrane ;  sometimes  the  tonsils  and  uvula  are 
greatly  swollen  and  spotted  with  exudation.  In  severe  cases,  more 
or  less  ulceration  or  sloughing  may  be  observed.  Not  infrequently 
fragments  of  exudation,  the  false  membrane,  are  expectorated,  with 
particles  of  the  ulcerated  tissues,  having  an  offensive  odor,  which  is 
transmitted  to  the  breath.     The  lymphatic  glands  of  the  neck  are 


ACUTE   GENERAL   DISEASES.  213 

enlarged  and  tender,  and  in  severe  cases  the  tissues  of  the  neck  are 
greatly  tumefied. 

Extension  to  the  nasal  cavities  causes  a  sanious  and  offensive 
discharge  from  the  nose,  with  attacks  of  epistaxis. 

Extension  to  the  larytix  is  indicated  by  hoarseness  or  cotnplete  loss 
of  voice,  croupy  cough,  and  obstructive  dyspnoea,  which  often  becomes 
urgent,  the  breathing  being  noisy  and stridulous,  and  subject  to  par- 
oxysmal exacerbations.  If  the  inflammation  extend  to  the  bronchi, 
the  breathing  becomes  still  more  embarrassed. 

Duration.  Ranges  from  two  to  fourteen  days,  an  average  being 
about  nine  days,  although  complications  and  sequelae  may  prolong  its 
course. 

Relapses  are  not  uncommon. 

Sequelae.  Those  who  recover  from  a  severe  attack  remain  often 
for  weeks  with  a  pale  and  cachectic  appearance,  due  to  the  profound 
blood  alteration. 

Paralysis  is  a  common  sequela,  following  the  mild  as  often  as  the 
severe  attacks.  Usually  not  occurring  until  the  patient  seems  fully 
convalescent. 

/%ary;z^^(2/ paralysis  is  most  common,  causing  difficulty  or  inability 
of  deglutition,  fluids  regurgitating  through  the  nose. 

Cardiac  paralysis,  bradycardia,  is  not  infrequent,  the  pulsations 
descending  to  60,  50,  40,  and,  in  a  case  seen  by  the  author,  to  20  per 
minute.  Heart  failure  and  fatal  syncope  may  occur  at  any  time 
during  the  disease. 

Diphtheritic  paralysis  may  affect  the  motor  muscles  of  the  eye, 
causing  strabistnus  ;  the  muscles  of  one  side,  hemiplegia  ;  of  the  legs, 
paraplegia ;  and  of  the  bladder,  leading  to  retention  of  urine  or 
difficulty  in  voiding  it. 

Multiple  neuritis,  with  the  attending  loss  of  power,  is  a  rare  sequela. 

Sensation  and  the  reflexes  are  diminished  in  the  paralyzed  parts. 

Diagnosis.  The  diagnosis  is  now  made  certain  by  making  a 
culture  from  the  deposit,  and  if  the  bacillus  is  present,  the  charac- 
teristic colonies  can  be  seen  in  the  course  of  twenty -four  hours,  under 
the  microscope. 

Yxom  follicular  ulceration  of  the  tonsils,  which  is  frequently  termed 
diphtheria,  by  the  slight  or  absent  systemic  symptoms,  the  ulcerated 
condition  being  limited  to  the  tonsils,  but  often  one,  and  the  absence 
of  glandular  enlargement,  and  following  palsies. 


214  PRACTICE    OF    MEDICINE. 

From  pharyngitis,  by  the  absence  of  exudation  and  loss  of  faucial 
tissue  and  constitutional  symptoms. 

From  scarlatina,  by  the  presence  of  the  eruption  and  the  absence 
of  membrane  in  the  fauces.  The  association  of  scarlatina  and  diph- 
theria must  not  be  forgotten. 

From  membranous  croup,  by  the  difference  in  the  constitutional 
symptoms;  croup  appears  sporadically  and  is  not  contagious,  diph- 
theria being  highly  contagious  and  frequently  occurs  in  epidemics; 
in  diphtheria  of  the  larynx  the  depression  is  clearly  that  of  blood- 
poisoning,  while  in  croup  the  depression  is  in  proportion  to  the 
mechanical  obstruction  of  the  respiration  by  the  membranous  exuda- 
tion. The  pathology  of  croup  is  simple  and  easy  of  investigation; 
diphtheria  is  obscure  in  its  etiology  and  progress.  The  temperature 
record  of  croup  is  a  high  one  until  carbonic  acid  poisoning  is  immi- 
nent from  the  mechanical  obstruction  to  respiration,  while  in  diph- 
theria the  tendency  to  a  decline  in  the  temperature  after  the  fourth 
day  is  nearly  characteristic,  regardless  of  the  amount  of  laryngeal 
obstruction.  In  croup  the  pharynx  contains  no  membrane,  and  is 
but  slightly,  if  at  all,  inflamed,  and  associated  trouble  in  the  nose  is 
of  the  rarest  occurrence,  the  very  reverse  obtaining  in  diphtheria.  In 
croup  the  laryngeal  symptoms  are  from  the  onset,  while  in  laryngeal 
diphtheria  the  pharyngeal  symptoms  almost  always  precede.  In 
croup  glandular  involvement  is  a  clinical  novelty,  as  are  subsequent 
palsies,  while  glandular  involvement  and  various  palsies  are  the  rule 
in  diphtheria.  Albuminuria  is  the  rule  in  diphtheria,  seldom  occur- 
ring in  croup. 

Prognosis.  Always  grave,  but  more  so  in  children  than  in 
adults.  Its  gravity,  in  the  majority  of  cases,  is  proportionate  to  the 
local  symptoms.     The  average  mortality  is  about  ten  per  cent. 

Favorable  indications  are,  moderate  fever,  strength  slightly  im- 
paired, a  good  constitution,  and  moderate  exudation. 

Unfavorable  indications  are,  high  fever,  great  depression,  spreading 
exudation,  great  swelling  of  the  cervical  glands,  large  amounts  of 
albumin,  extension  to  larynx  and  nasal  mucous  membranes,  hemor- 
rhages from  the  fauces  and  nose,  and  an  epidemic  character. 

Treatment.  The  introduction  of  the  antitoxin  serum  has  changed 
the  proj:,^nosis  of  this  formidable  malady.  The  injections  are  made 
where  the  skin  is  loose  and  at  points  that  will  not  interfere  with  the 
comfort  of  the  patient.     The  dose  must  be  estimated  in  antitoxic 


ACUTE   GENERAL    DISEASES.  215 

units,  and  not  by  the  unit  of  the  serum.  The  dose  is  from  looo  to 
3000  units,  according  to  the  severity  of  the  attack.  If  the  dose  is 
sufficient,  evidences  of  improvement  are  seen  within  a  few  hours. 
With  the  serum-therapy  must  be  associated  the  constitutional  treat- 
ment, as  it  is  a  disease  of  great  debility,  and  the  blood  being  more  or 
less  altered,  it  follows  that  sustaining  measures  should  be  resorted  to 
in  all  cases. 

The  diet  should  be  of  the  most  nutritious  character,  from  the  onset, 
using  such  articles  as  milk,  eggs,  broths,  and  oysters,  at  intervals  of 
every  two  or  three  hours.  If  deglutition  be  too  painful,  resort  must  be 
had  to  nutritious  enemata,  the  following  being  a  suitable  formula  : 

R.     Milk, fgj  30.    Cc. 

Spts.  frumenti, ^3'^  ^S-     ^^• 

Egg, One  M. 

SiG. — Little  salt  added,  beaten  up  and  warmed. 

Stimulants  should  be  used  boldly  from  the  onset,  guiding  the  dose 
by  the  effect ;  usually  a  child  of  two  years  requires  from  thirty  \.o  sixty 
minims  (2-4  Cc.)  of  spirittis  vini  gallici  or  spiritus  frumenti  every 
two  or  three  hours  ;  an  adult  from  two  to  four  drachms  (8-1 5  Cc.) 
every  three  hours.  It  is  a  mistake  to  wait  for  signs  of  debility  before 
using  alcohol  in  diphtheria.  Strychnince  sulphas,  in  frequent  doses, 
should  be  used  from  the  onset. 

Of  drugs,  two  are  warmly  advocated ;  ferrum  and  hydrargyrum. 
Of  the  great  value  of  tinctura  ferri chloridi  there  is  no  question,  but 
for  hydrargyri  chloridum  corrosivum  it  has  hardly  realized  the 
expectations  of  the  profession,  except  in  laryngeal  cases.  A  com- 
bination of  ferrum  and  potassii  chloras,  in  full  doses,  frequently 
repeated,  has  seemed,  when  begun  early  in  the  attack,  to  modify 
the  course  of  the  malady,  and  they  have  the  additional  advantage 
of  acting  locally  upon  the  throat  as  they  are  swallowed.  A  good 
formula  is — 

B-     Tinct.  ferri  chlor., TtLv-x  .3-6  Cc. 

Potassii  chlor., gr.  iij-v  -2-. 3  Gm. 

Glycerini, f.^ss  2.  Cc. 

Syr.  zingib., ad  fgj-ij  ad  4.-8.  Cc.  M. 

SiG. — In  water  every  three  hours,  for  a  child  of  two  or  three  years. 

Ferrum  and  hydrargyri  chloridum  corrosivum,  repeated  every 
second  or  third  hour,  may  be  combined  as  follows : 


216  rRACTICE    OF    MEDICINE. 

K-     Ilydrargyri  chloridi  corrosiv.,   .    gr.  ^'^  .0015  Gm. 

Tinct.  fcrri  chloridi, n\,v-x  .3-.6  Cc. 

Giycerini, Tt\^x  .6       Cc. 

Aqiue,      (^'}  4.  Cc.  M. 

SiG.  —  Every  hour  or  tsvo,  well  diluted. 

The  efficacy  of  the  above  is  greatly  enhanced  by  the  addition  to 
each  dose  of  iinctura  belladonncF,  tt\,  j-v  (0.06-0.3  Cc). 

QuinincE  sulphas,  gr.  xvj-xxiv  (1-1.56  Gm.)  per  day  for  a  young 
adult,  and  gr.  v-x  (0.3-0.6  Gm.)  for  a  child,  should  be  used  through- 
out the  disease  ;  if  irritability  of  the  stomach  prevent  its  administra- 
tion by  the  mouth,  it  can  be  used  as  a  suppository,  or  locally  in  the 
form  of  the  oleate. 

Sustain  the  heart  with  either  digiialis,  glonoin,  ca(feifia:  citrata,  or 
strychnines  sulphas,  or  a  combination  of  these  drugs. 

Calomel  \n  small  doses,  combined  with  sodii  bicarbotias  every  hour 
until  it  is  beneficial,  and  especially  in  cases  showing  a  tendency  to 
spread  toward  the  larynx.  Indeed,  a  tolerance  to  calomel  seems  to 
exist  in  diphtheria  of  the  larynx. 

Watch  the  urine  carefully  throughout  the  disease  ;  diminution  in 
the  amount  with  much  albumin  is  of  bad  omen.  The  bowels  must  be 
regular. 

Isolation  of  the  patient  and  disinfection  of  the  clothing  and  utensils 
is  of  importance.  All  clothing  should  be  soaked  twenty-four  hours 
and  boiled  in  a  two  per  cent,  solution  of  carbolic  acid. 

Inhalations  of  steam  and  hot  water,  and  allowing  the  patient  to 
suck  pellets  of  ice,  give  relief.  Sponges  dipped  in  hot  water  and 
applied  to  the  angles  of  the  jaw  are  beneficial. 

The  chief  danger  of  communication  of  the  poison  is  the  air  exhaled 
from  the  fauces  and  from  the  surface.  Dr.  J.  Lewis  Smith  recom- 
mends the  following  plan  to  counteract  the  danger.  Add  four  ounces 
of  the  following  solution  to  one  quart  of  water  and  allow  them  to 
simmer  constantly,  near  the  patient,  in  a  broad  surfaced  tin  or  zinc 
wash-basin  :  R.  Olei  eucalypt.,  acidi  carbolici,  aa  f5J  (30  Cc.)  ;  spirit, 
terebinthinae,  f  J  viij  (240  Cc).  M.  The  vapor  is  strong,  penetrating, 
and  prophylactic,  but  not  unpleasant.  In  hot  weather,  or  when  a  fire  is 
not  convenient,  saturate  cloths  a  foot  square  with  the  same  solution 
and  place  them  on  paper  on  the  bed  of  the  patient. 

Locally.  Two  indications  to  be  met,  one  to  prevent  or  limit  the 
local  development  of  the  bacilli,  and  the  other  to  combat  the  effects 


ACUTE   GENERAL   DISEASES.  217 

of  the  toxic  material  which  the  bacilli  produce.  The  first  question 
asked  is,  Can  we  dissolve  the  membrane  ?  "  In  laboratory,  yes  ;  in 
throat,  no."     (Da  Costa.) 

Cleanliness  of  the  fauces  is  of  the  utmost  importance,  and  if  a  non- 
irritatittg  disinfectant  be  added,  its  value  is  enhanced.  Prof.  Bar- 
tholow  "  has  seen  excellent  results  from  the  frequent  application  of  r- 
solution  oi  acidnni  lactictan,  strong  enough  to  taste  sour,  by  means  of 
a  mop."  Excellent  results  are  obtained  from  spraying  the  throat 
with  a  fifty  per  cent,  solution  of  hydrogen  peroxide.  Swabbing  the 
throat  with  the  following  is  valuable : 

K.     Acidi  carbolici, TTLxx  I.3  Cc. 

Tinct.  ferri  chlor. ,      ^Tt^'^  1 5-     ^^^ 

Glycerini, f_^j  30.     Cc. 

Aq.  destil, fgj  30.     Cc.  M. 

SiG. — Locally,  every  three  hours. 

Applications  of  corrosive  sublimate  to  the  throat  are  often  valuable. 
Dr.  Ernest  Laplace  has  demonstrated  that  corrosive  sublimate  in 
solution,  slightly  acidulated  with  tartaric  acid,  has  its  germicide  prop- 
erty increased,  as  in  the  following  1-500  solution  (R.  Hydrargyri 
chlor.  corrosiv.,  gr.  3.85;  acid  tartaric,  gr.  19.25.     M.) 

The  following,  used  as  a  gargle,  or  applied  by  a  mop,  is  useful : 

R.     Potass,  chlorat., ^5  iv  15.  Gm. 

Acid,  carbol., gr.  ij-iv  .13— .26  Gm. 

Tinct.  myrrh., f^j  30.  Cc. 

Inf.  cinchonse, f  ^  ij  60.  Cc.      M. 

It  is  a  mistake  to  struggle  with  children  over  their  refusal  to  use  a 
gargle  or  allow  the  use  of  the  spray,  as  they  do  not  know  how  to  gargle 
and  they  are  afraid  of  the  spray.  Much  better  to  add  plenty  of 
glycerin  to  their  medicine,  and  use  no  liquid  for  some  time  after  swal- 
lowing. 

For  laryngeal  diphtheria  the  same  general  treatment,  especially 
the  merctirial ,  with  inhalations  of  lime  by  slaking  freshly-burned 
lime  in  a  vessel  and  directing  the  vapor  to  the  child  by  a  newspaper, 
or  some  similar  contrivance,  or  using  three  parts  of  liquor  calcis  and 
one  part  oi glyceriniwi  in  an  atomizer,  every  half  hour  or  hour,  or  liquor 
trypsin,  as  a  spray.  If  these  means  fail,  resort  must  be  had  to  trache- 
otomy, or  intubatio7i  of  the  larynx,  which  have  succeeded  in  many 


218  PRACTICE   OF    MEDICINE, 

desperate  cases.     It  is  safer  to  insert  a  tube  at  the  onset  in  all  cases 
of  laryngeal  diphtheria. 

For  nasal  diphtheria,  the  same  general  treatment,  and  syringing 
the  nose  every  two  or  three  hours  with  a  weak  solution  oi  potassii 
chloras,  or  aciduin  carbolicum,  or  hydrogen  peroxide,  or  the  follow- 
ing: 

li  .     Sodii  sulpbit. 3  iij  12.     Gm. 

Glycerin!, f  %  ij  8.     Cc. 

Aquce,      f  5 'v  ^20.     Cc. 

For  the  paralysis,  strychnines  sulphas  and  femon  internally,  01 
strychnines  sulphas  hypodermically,  with  the  galvanic  or  faradic 
current  locally. 


GLANDERS. 

Synonyms.     Farcy  ;  malleus  humidus. 

Definition.  An  infectious  disease  of  the  horse,  communicable  to 
man  and  some  domestic  animals,  but  not  to  cattle;  characterized  by 
nodular  growths  in  the  nose — glanders,  and  under  the  skin — farcy. 

Cause.  Due  to  a  specific  bacillus — bacillus  Mallei.  The  organ- 
ism resembles  the  tubercle-bacillus,  though  somewhat  shorter  and 
thicker.  Communicated  by  the  discharge  from  an  infected  animal  to 
an  abraded  skin  or  mucous  surface.  Contagious.  Incubation  from 
three  to  five  days. 

Pathological  Anatomy.  Nodules,  consisting  of  aggregations 
of  round  cells  of  lymphoid  or  polymorphonuclear  type,  which  have 
a  strong  tendency  to  suppurative  or  necrotic  softening.  The  floor 
and  edges  of  the  ulcers  (softened  nodules)  are  irregular  and  yellow- 
ish, discharging  more  or  less  purulent  matter.  The  nodules  develop 
particularly  in  the  nares  and  the  skin,  and,  rarely  in  the  lungs.  The 
lymphatic  glands  of  the  neck  and  elsewhere  enlarge  and  may  sup- 
purate. 

Symptoms.     There  is  an  acute  and  a  chronic  form  of  glanders. 

Acute  glanders.  Redness  and  swelling  oi  the  nasal  mucous  mem- 
brane with  burning  and  dryness,  followed  by  the  development  of  the 
tiodules,\\\\\z\\  rapidly  breakdown  and  discharge  a  fetid  hemorrhagic 
or  muco-pus.  There  is  headache,  painful  deglutition,  cough,  fever, 
prostration,  rapidly  developing  typhoid  symptoms,  and  death. 


ACUTE   GENERAL   DISEASES.  219 

Acute  farcy  or  glanders  of  the  skin  is  a  nodular  swelliftg  w'lih.  subse- 
quent ulcers  and  discharge  of  a  fetid  hemorrhagic  pus  on  the  skin. 
Papules,  becoming  pustules,  followed  by  ulceration,  occur  in  the 
neighborhood  of  the  nodules.  The  lymphatic  glands  and  vessels 
are  involved,  but  not  the  nose.  Prostration  and  typhoid  symptoms 
rapidly  develop. 

In  the  chro7iic  variety  the  development,  course,  and  symptoms  are 
all  more  backward  and  of  less  severity. 

Diagnosis.  The  certainty  of  diagnosis  is  made  possible  by  mak- 
ing cultures. 

Prognosis.  Acute  variety  fatal.  Chronic  variety,  if  early  diag- 
nosed, many  may  recover. 

Treatment.  Palliative  and  surgical  means  for  the  lesions.  It  is 
possible  the  serum-therapy  may  soon  be  able  to  control,  cure,  or 
modify  this  fatal  disease. 

ACUTE  ARTICULAR  RHEUMATISM. 

Synonyms.     Rheumatic  fever;  inflammatory  rheumatism. 

Definition.  A  constitutional  disease,  characterized  by  fever,  in- 
flammation in  and  around  the  joints,  occurring  in  succession,  and  a 
great  tendency  to  inflammation  of  either  the  endocardium  or  peri- 
cardium. 

Causes.  The  predisposing  causes  are  inherited  tendency,  scarla- 
tina, and  the  puerperal  state. 

The  exciting  causes  are  exposure  to  cold  and  chilling  of  the  body 
in  those  predisposed.  Rheumatism  rarely  occurs  before  seven  or  after 
fifty  years.  The  liability  to  the  disease  is  increased  by  having  had 
an  attack.  It  is  claimed  that  a  specific  bacteria  has  been  found  in 
the  swollen  joints,  which  may  prove  to  be  the  etiological  factor  in  the 
production  of  the  painful  affection. 

Pathological  Anatomy.  The  blood  contains  an  excess  of  lactic 
acid.  The  Joints  bear  the  brunt  of  the  attack ;  the  synovial  mem- 
brane is  reddened,  the  vascularity  of  the  synovial  fringes  is  increased  ; 
so  with  the  synovial  fluid,  which  is  thinner,  of  a  reddish  color,  con- 
taining some  gelatinous  coagula  of  fibrin,  and,  under  the  microscope, 
nucleated  cells,  ordinary  pus  cells  being  rarely  seen. 

The  swelling  visible  from  the  affected  part  depends  mostly  on 
inflammatory  oedema  of  the  connective  tissue  around  the  joint. 


220  rUACTICE    OK    MKDICINE. 

The  pain  is  probably  due,  in  all  cases,  to  stretching  of  and  press- 
ure  on  the  elements  of  the  tissues  by  the  dilated  capillaries  and  the 
inflammatory  oedema.  For  the  changes  which  ensue  when  theendo- 
and  pericardium  are  attacked,  the  reader  is  referred  to  the  sections  on 
those  diseases. 

Symptoms.  Begins  suddenly,  generally  at  night,  with  a  chill  ox 
chilliness, />a/«  and  stiffness  in  the  joints,  loss  of  appetite,  at  times 
nausea  and  vomiting,  followed  hy  fever,  the  temperature  soon  reach- 
ing 102°  to  104°  F.,  in  rare  cases  108°  to  1 10°  {the  hyperpyrexia),  the 
pulse  seldom  exceeding  g^,  great  thirst,  profuse  acid  sweats,  scanty, 
high-colored,  acid  urine,  at  times  showing  traces  of  albumin  ;  the 
bowels  constipated.  The  fever  continues  throughout  the  attack,  show- 
ing marked  remissions.  Delirium  is  absent,  except  the  hyperpyrexia 
occur.  6"/!?^^  is  prevented  by  Xhe  pain  and  the  profuse  perspirations. 
The  strength  is  moderately  well  preserved. 

The  s^in  is  often  covered  with  an  eruption  of  viiliaria  rubra,  red 
papules,  and  miliaria  alba,  the  result  of  irritation  at  the  orifices  of  the 
sweat  glands,  from  the  excessive  perspiration. 

The  local  phenomena  Vive  pain,  tenderness,  increased  heat,  swelling; 
and  redness  of  one  or  more  joints;  if  but  one  joint,  it  is  termed 
tnonoarthritis ;  if  more  than  ont,  polyarthritis.  Paiti  is  aggravated 
hy  motion  2inA  pressure.  Swellifig  is  most  apparent  in  those  joints 
not  covered  with  muscle,  as  the  knee,  wrist,  elbow,  ankle,  and  the 
hands  and  feet,  and  is  proportionate  to  the  acuteness  of  the  attack. 
The  inflammation  may  abruptly  cease  at  one  or  more  joints,  and  as 
suddenly  attack  others. 

The  disease  is  extremely  irregular  as  regards  the  number  of  joints 
affected,  although  the  local  manifestations  are  controlled  by  an 
important  pathological  law,  the  law  of  parallelism.  Correspond- 
ing joints  are  often  affected  together,  and  when  not,  the  different 
affected  joints  are  either  on  one  side  of  the  body,  or  those  on  both 
bides  which  are  analogous,  as  the  knee,  elbow,  wrist,  ankle,  hip,  and 
shoulder,  are  attacked  together. 

Complications.  Pericarditis,  endocarditis,  myocarditis,  cerebral 
endarteritis,  bronchitis,  pneumonitis,  and  pleuritis. 

Duration.  The  duration  of  acute  rheumatism  is  governed  entirely 
by  the  presence  or  absence  of  complications.  Uncomplicated  cases 
recover  in  from  thirteen  to  twenty  one  days,  although  they  may  be 
prolonged  to  five  or  six  weeks.     Relapses  are  frequent. 


ACUTE  GENERAL   DISEASES.  221 

Diagnosis.  A  typical  case  cannot  be  mistaken  for  any  other 
disease,  but  cases  running  a  subacute  course  may  be  mistaken  for 
acute  rheumatoid  arthritis,  gonorrhoeal  rheumatism,  or  pyaemia. 

Acute  rheumatoid  arthritis  attacks  one  joint  at  a  time  and  becomes 
permanent,  has  slight,  if  any  fever,  no  sweats  or  cardiac  lesions. 

Gonorrhoeal  rheumatism  is  associated  with  a  gleety  discharge,  or 
follows  the  sudden  cessation  of  an  acute  or  subacute  gonorrhoeal 
discharge,  attacks  either  the  ankle  or  wrist  only,  is  slowly  influenced 
by  treatment,  and  lacks  the  febrile  phenomena. 

PycE7nia  is  usually  manifested  at  a  single  joint  at  the  time,  and  is 
followed  by  suppuration  and  all  the  symptoms  of  hectic  fever. 

Prognosis.  Recovery  is  the  rule  in  uncomplicated  cases,  the 
mortality  being  about  three  per  cent.  When  death  occurs,  it  usually 
depends  upon  hyperpyrexia,  cardiac  complication,  or  cerebral  end- 
arteritis. 

Treatment.  Owing  to  our  imperfect  knowledge  of  the  exact 
nature  of  this  most  painful  disease,  its  treatment  still  remains  either 
empirical  or  is  directed  toward  certain  prominent  symptoms  or  com- 
plications. Garrod  claims  that  "colored  water"  is  about  as  potent 
as  anything  else,  for  it  is,  he  says,  a  "self-limited  disease,"  some- 
times running  a  long  and  sometimes  a  short  course. 

Rest  in  bed,  whether  the  pain  forces  it  or  not,  is  important. 
Warmth  is  as  imperative,  for  which  purpose  the  patient  should  be 
kept  in  blankets — no  sheets — and  wear  woolen  garments.  The  diet 
should  be  easily  digested  food,  milk  being  the  most  suitable. 

Strong  and  vigorous  patients  do  well  with  acidum  salicylictan  or 
the  salicylates  in  large  and  frequently  repeated  doses. 

R.     Acidi  salicylici, Iss  15.  Gm. 

Liq.  ammonii  acetat., f^i^  \20.  Cc. 

Spts.  Eetheris  nitrosi, f  5j  30.  Cc. 

Syr.  simplicis, f^j  30.  Cc.  M, 

SiG. — Tablespoonful  every  three  hours,  well  diluted. 

Or— 

R.     Sodii  salicylat., ^^j  30.  Gm. 

Tinct.  cinchonse  comp. ,     ....  fSiij  90.  Cc. 

Aq.  menth.  pip., f § 'U  9°-  Co.  M. 

SiG. — Dessertspoonful  every  three  or  four  hours  till  relief,  when  widen 
the  interval. 


222  PRACTICE    OF    MEDICINE, 

Or— 

R.     Potassii  acetat ^j  30.  Gm. 

Acid,  salicylici, s  ss  15-  Gm. 

Syr.  limonis, f.^'j  ^-  ^^• 

A(\.  meiith.  pip., '^o^'"J  ^4°-  ^^-  ^' 

SiG. — Tabiespoonful  every  three  hours,  diluted. 

If  benefit  follows,  the  evidence  is  quickly  afforded  in  the  relief  of 
pain  and  the  decline  of  the  temperature  and  swelling.  If,  therefore, 
after  three  or  four  days'  use  of  the  salicylates  or  acidum  salicylicum, 
as  above  recommended,  signs  of  improvement  are  wanting,  the  treat- 
ment had  better  be  changed  for  the  alkaline  treatment,  which  consists 
in  the  administration  of  an  ounce  and  a  half  of  the  alkaline  carbon- 
ates, either  alone  or  with  a  vegetable  acid,  each  twenty-four  hours, 
until  the  urine  becomes  neutral  or  alkaline,  when  the  quantity  i= 
reduced  to  an  amount  sufficient  to  maintain  alkaline  urine. 

The  following  are  good  formulae  for  the  alkaline  treatment: 

R.     Potassii  bicarbonatis, ^ij  8.  Gm. 

Acid,  tartarici, gr.  xxx  2.  Gm. 

Dissolve  in  a  glass  of  water  and  drink  effervescing  every  three  hours. 

Or— 

R  .     Potass,  bicarb. 3  ij  8.  Gm. 

Succi  limonis, f^iv  15.  Cc. 

Aqure  chloroform! fo^^  ^5-  Cc.  M. 

SiG. — In  water,  every  three  hours. 

After  the  more  acute  symptoms  are  relieved  change  whichever 
plan  of  medication  has  been  used  for  iinchira  ferri  chloridi,  tt)^xx 
(1.3  Cc),  every  three  or  four  hours,  well  diluted,  or  for  full  doses  of 
Basham's  mixture. 

Pale,  feeble,  and  anaemic  patients,  or  attacks  following  scarlatina 
are  most  favorably  influenced  by — 

R.     Strychnin?e  sulph., gr-  ?V  .001  Gm. 

Tinct.  ferri  chlor.,      TT\^xv-xxx  I. -2.         Cc. 

Liquor,  ammonii  acetat.,   .    .    .    .  f 'ss  15.              Cc.      M. 
SiG. — Every  four  hours,  in  a  glass  of  water. 

Dr.  S.  Solis-Cohen  has  reported  good  results  from  the  following 
combination  in  anaemic  and  run-down  cases,  to  which  he  has  given 
the  name  of  "  mistura  ferro-salicylata  "  : 


ACUTE  GENERAL   DISEASES.  223 

R.     Sodii  salicylatis,     .    , ziv  15.  Gm. 

Glycerini, f^j  30.  Cc. 

Acidi  citrici, gr-  x  .6  Gm. 

01.  gaultherise, f^ss  2.  Cc. 

Mucil.  acacise, f^ss  15.  Cc. 

Misce  tt  adde  while  stirring, 

Tinct.  ferri  chlorid., ^5'^  ^S-  Cc.              M. 

Liq.  ammonii  citrat.  (B.  P.),  ad  f^iv  ad  120.  Cc. 
SiG. — One  to  two  teaspoonfuls  every  two,  three,  or  four  hours,  diluted. 

Prof.  Da  Costa  reports  a  lessened  proportion  of  cardiac  compli- 
cations with  ammonii  broinidtan,  gr.  xv-xx  (1-1.3  Gm.),  every  four 
hours.  I  much  prefer  ajjtfnonii  salicylas,  gr.  x-xv  (06-1  Gm.),  in 
simple  syrup,  well  diluted,  every  four  to  six  hours. 

Subacute  attacks  and  lingering  cases  are  favorably  influenced  by 
cinchonidi7tcE  salicylas,  gr.  v  (0.3  Gm.),  every  four  hours,  or — 

5k  .     Lithii  salicylatis, gr.  xv-xx  I.-I.3  Gm. 

Syr.  zingiberis, f^j  4.  Cc. 

Aq.  lauro-cerasi, f^j  4.  Cc.  M. 

Every  four  hours. 

Or— 

R.     Potassii  iodidi, J^iv  5.3  Gm. 

Sodii  salicylatis,      ^iv  15.  Gm. 

Elix.  cinchonas, f.^iss  45.  Cc. 

Infus.  gentianae, f.S^^^  45-  ^^• 

Aquse  destil., fjj  30.  Cc.  M. 

SiG. — Dessertspoonful  every  three  or  four  hours,  diluted. 

Good  results  are  reported  from  the  use  of  salol,  gr.  v-x  (0.3-0.6  Gm.), 
every  four  hours,  from  ammonii  hydrochloras,  gr.  xv-xx  (1-1.3  Gm.), 
every  four  hours,  and  from  salipyrin  in  solution,  every  four  hours  ; 

R.      Salipyrin, ^iij  1 2.  Gm. 

Glycerini, f^i'j  12.  Cc. 

Syr.  aurantii, f .^  vj  24.  Cc. 

Aquae  destil., ad  f^vj  ad  180.  Cc.          M. 

SiG. — Tablespoonful,  well  diluted. 

Whichever  plan,  acidum  sahcylicum,  salicylates,  alkahne,  or  fer- 
rum,  is  adopted,  guinittcs  sulphas,  gr.  xv  (i  Gm.),  per  day,  should 
also  be  used. 

Pain  and  restlessness  should  be  controlled  by  opium  in  some  form, 
in  full  doses,  or  atropines  sulphas,  gr.  -g^j  (0.0008  Gm.),  hypodermic- 
ally. 


224  PRACTICE    OF    MEDICINE. 

For  the  hyptrpyrexiix,  quinhta:  sulphas,  gr.  xxx-lx  (2-4  Cim.), 
repeated  p.  r.  n.,  with  the  cold  bath  or  wet  pack. 

Locally,  the  affected  joints  should  be  wrapped  in  cotton-wool  or 
flannel,  saturated  with  a  solution  of  tinctura  opii,  one  part,  and  liq. 
plumb,  subaceiat.  dil.,  two  parts,  or  olei  gaiilthericr ,  foj  (4  Cc),  with 
lin.  saponis  comp.,  f5iij  (90  Cc),  or — 

Ht.     Sodii  bicarboiiatis, _^  i j  60.  Gm. 

Tinct.  opii, f.^ss  15.  Cc. 

Aqucebul., Oij  960.  Cc.  M. 

Dr.  Bartholow  finds  the  application  of  blisters  an  effective 
method.  He  says  :  "  I  have  small  blisters,  the  size  of  a  silver  dollar, 
placed  around  the  joint,  leaving  an  interval  between  for  succeeding 
applications.  It  is  by  no  means  so  painfiil  and  disagreeable  as  it 
appears  at  first  sight.  The  blisters  remarkably  relieve  the  pain,  bring 
about  a  more  alkaline  condition  of  the  blood,  and  render  the  urine 
less  acid,  or  bring  it  to  neutral,  or  even  to  alkaline." 

If  the  disease  shows  a  tendency  to  linger  in  one  or  more  joints,  such 
joints  should  be  immediately  placed  in  the  hot-air  apparatus. 


MUSCULAR  RHEUMATISM. 

Synonyms.  According  to  location:  cephalodynia;  lumbago; 
torticollis  ;  pleurodynia. 

Definition.  An  affection  of  the  voluntary  muscles,  inflammatory 
in  character,  either  actite  or  chronic ;  characterized  by  pain,  tender- 
ness, and  stiffness  of  the  affected  muscles.  It  is  never  complicated 
with  cardiac  disease. 

Causes.  A  disease  of  adult  life.  One  attack  predisposes  to  an- 
other. Almost  always  due  to  cold  or  damp,  or  direct  draught  of  cold 
air.     Gout  increases  the  tendency  to  attacks. 

Pathological  Anatomy.  The  true  nature  of  muscular  rheu- 
matism is  not  yet  determined.  Virchow  suggests  a  "  hypersemia  of, 
and  scanty  serous  exudation  between,  the  muscular  stria:,  and  in 
chronic  cases  inflammatory  proliferation  of  the  connective  tissue." 

Symptoms.  The  first  attack  is  generally  acute.  Onset  rather 
sudden,  with  pain  in  the  affected  muscles,  with  slight  tenderttess,2indi 
considerable  stiffness  and  difficulty  of  movement,  by  which  also  the 
pain  is  increased. 


ACUTE   GENERAL   DISEASES.  225 

The  suffering  may  be  severe  and  constant,  or  only  on  motion. 
Spasm  of  the  affected  muscles  may  occur.  Objective  symptoms  are 
wanting,  except  it  is  evident  that  the  patient  keeps  the  affected 
muscles  as  quiet  as  possible.  Fever  is  absent.  The  pain  may  pre- 
vent sleep. 

Duration,  acute  form,  about  one  week.  Chronic  variety  returns  fre- 
quently, and  finally  becomes  constant  and  aggravated  when  the 
weather  is  damp. 

Varieties.  It  may  affect  any  or  all  of  the  voluntary  muscles,  but 
its  most  frequent  and  important  varieties  are  : 

1.  Cephalodynia.  Situated  in  the  occipito-frontal  muscles.  Dis- 
tinguished from  neuralgia  of  the  trifacial,  or  occipital  nerve,  by  pain 
on  both  sides  of  the  head,  excited  or  aggravated  by  the  movements 
of  the  muscle  and  by  absence  of  disseminated  points  of  tenderness. 

The  muscles  of  the  eye  may  be  affected,  and  movements  of  that 
organ  excite  pain.  If  the  temporal  and  masseter  muscles  are 
attacked,  mastication  excites  pain. 

2.  Torticollis.  Wry  neck,  or  stiff  neck.  Situated  in  the  sterno- 
mastoid  muscles.  Generally  limited  to  one  side  of  the  neck,  toward 
which  side  the  head  is  twisted,  great  pain  being  excited  on  attempting 
to  turn  to  the  opposite  side.  Rheumatism  of  the  muscles  of  the  back 
of  the  neck,  cervicodynia,  may  be  mistaken  for  occipital  neuralgia. 

3.  Pleurodynia.  Situated  in  the  thoracic  muscles,  and  may  be 
mistaken  for  pleuritis,  or  intercostal  neuralgia,  from  which  it  is  differ- 
entiated by  the  absence  of  the  diagnostic  features  of  each.  Pain  is 
excited  by  forced  breathing,  coughing,  and  sneezing. 

4.  Lwnbodynia  or  lumbago.  Situated  in  the  mass  of  muscles  and 
fascise,  which  occupy  the  lumbar  region.  Most  common  variety. 
Usually  affects  both  sides.  It  may  set  in  rapidly,  and  become  very 
severe.  Motion  of  any  kind  aggravates  the  pain,  often  becoming 
very  sharp  or  stabbing  in  character.  It  is  sometimes  complicated 
with  acute  sciatica,  when  the  suffering  is  agonizing. 

Diagnosis.  The  different  varieties  may  be  mistaken  for  any  of 
the  following  ailments,  to  wit :  trifacial,  occipital,  or  intercostal  neu- 
ralgia, pains  of  progressive  muscular  atrophy,  neuritis,  syphilis, 
metallic  poisons,  or  painful  affections  of  the  loins,  arising  from  calculi 
or  gravel  in  the  kidney. 

A  careful  examination  of  the  history  is  usually  sufScient  to  arrive 
at  a  correct  diagnosis. 
15 


22f)  PRACTICE    OF    MEDICINE. 

Prognosis.  Difficult  to  eradicate,  and  in  chronic  cases  to  amelio- 
rate, but  is  not  dangerous  to  life.     Death  never  results. 

Treatment.  Rest  is  the  first  indication.  This  is  accomplished 
\x\  pleurodynia  by  firmly  strapping  the  affected  side  with  broad  strips 
of  plaster,  extending  from  mid-spine  to  mid-sternum. 

The  A'a// application  to  the  aflfected  muscles  of //^/poultices,  made 
oiXwo-^w^s  pilocarptis  leaves  and  ov\t-\}[\\xdL.  flaxseed  meal,  changing 
them  every  two  hours,  is  the  most  rapidly  successful  treatment  in  acute 
cases. 

Internally,  ajtiipyritt,  gr.  x-xx  (0.6-1.3  Gm.),  repeated  in  several 
hours,  or  ammonii  hydrochloras,  ^x,yM-\y.  (1-1.3  Gm.),  every  three 
hours,  or  sodii  salicylas,  gr.  xv-xx  (1-1.3  Gm.),  every  two  or  three 
hours,  are  each  of  value.  Prof.  Bartholow  declares  that  Hthii 
bromidum  is  almost  a  specific  in  muscular  rheumatism. 

For  \}ci&  pain  and  consequent  sleeplessness,  use — 

B .     Pulv.  ipecac,  et  opii, gr.  x  .6        Gm. 

Potass,  nitrat., gr.  v-x  .3-.6Gm.         M. 

SiG. — In  powder,  morning  and  night. 

Or,  hypodermically,  at  the  seat  of  pain,  tnorphina  sulphas,  gr.  %- 
^  (0.008-0.016  Gm.),  and  atropines  su/p/ias,  gr.  ^^^j  (0.0008  Gm.), 
p.  r.  n. 

In  attacks  where  the  disease  is  limited  to  a  few  muscles,  the  follow- 
ing liniment  is  valuable  : 

R.     01.  gaultherlffi, jiss  6.   Cc. 

Spirit,  vini  rectif.,  ...■••.  f^ij  60.    Cc.  M. 

SiG. — Thoroughly  rub  into  affected  part. 

In  all  forms,  but  more  particularly  in  lumbago,  a  few  dry  cups  over 
the  seat  of  the  pain  give  immediate  relief. 

Wonderful  results  have  followed  the  use  of  the  hot-air  apparatus 
in  acute  and  subacute  lumbago. 

Chronic  cases  :  Rest,  flannel  worn  next  to  the  skin,  stimulating  and 
anodyne  liniments,  mild  galvanism,  dry  heat,  as  ironing  over  the 
affected  part  with  a  common  flat-iron,  a  piece  of  paper  or  towel 
being  placed  next  to  the  skin. 

InXernviWy ,  potassil  iodidum,  ammonii  hydroc Moras,  sulphur,  guai- 
acton  or  arsenicum  variously  combined. 


ACUTE  GENERAL   DISEASES.  227 


RHEUMATOID  ARTHRITIS. 

Synonyms.     Arthritis  deformans ;  rheumatic  gout  (?). 

Definition.  A  destructive  disease  of  the  joints,  accompanied 
with  but  slight  fever,  without  suppuration  ;  progressive  in  character, 
causing  nearly  symmetrical  enlargement  and  deformity  of  various 
articulations. 

Causes.  The  neuro-trophic  theory,  as  advocated  by  Mitchell 
(J.  K.)  and  supported  by  Charcot,  is  accepted  as  the  predisposing 
cause."  Among  the  exciting  causes  are  bad  hygiene,  exposure,  injury, 
prolonged  lactation,  frequent  pregnancies,  menopause,  grief,  tuber- 
cular diathesis,  and  following  attacks  of  articular  rheumatism.  More 
common  in  women  than  men.     A  disease  of  middle  life. 

Pathological  Anatomy.  It  is  not  rheumatism,  as  the  blood 
contains  no  lactic  acid.  It  is  not  gout,  as  uric  acid  is  not  found  in  the 
blood  nor  urate  of  sodium  in  the  joints. 

At  first  rheumatoid  arthritis  is  attended  with  hypersemia  of  the 
affected  synovial  membrane  and  increase  of  the  synovial  fluid.  Soon 
the  capsular  ligament  becomes  irregularly  thickened,  the  synovial 
fluid  decreasing.  If  the  process  continue,  the  internal  ligament  is 
destroyed,  thus  allowing  dislocation  to  occur.  The  interarticular 
fibro-cartilages  ulcerate  and  disappear,  as  do  the  cartilages  covering 
the  ends  of  the  bone,  the  ends  of  the  bones  becoming  smooth  and 
eburnated,  and  often  greatly  enlarged. 

Symptoms.     Either  acute  or  chronic,  the  latter  more  frequent. 

Acute  form  involves  several  joints  at  the  same  time,  and  is  attended 
with  slight  pyrexia. 

Chronic  form  slowly  involves  one  joint,  which  seemingly  soon 
recovers,  and  is  attacked  again,  and  may  never  recover,  but  grows 
progressively  worse. 

The.  Joint  slowly  enlarges,  is  painful,  movement  exciting  neuralgic 
pains  along  the  limb.  Soon  the  articulations  become  rigid  or  slightly 
movable  after  prolonged  attempts,  are  more  or  less  distorted  and 
flexed,  with  nodules  (Heberden's  nodosities)  on  the  sides  or  ends  of 
the  distant  phalanges.  Redness  and  tenderness  are  wanting.  The 
muscles  of  the  affected  limb  waste,  giving  the  joint  a  greatly  hyper- 
trophied  appearance.  Crepitation  is  distinct  after  ulceration  has 
destroyed  the  cartilage. 


'2l28  PRACTICE   OF    MEDICINE. 

The  hands  are  first  involved,  the  disease  spreading  symmetrically 
from  articulation  to  articulation,  until  in  severe  cases  every  joint  is 
deformed. 

Diagrnosis.  Chronic  articular  rhcKmaiistn  is  often  confounded 
with  rheum;itoid  arthritis;  but  the  former  lacks  the  marked  structural 
changes  and  the  progressive  involvement  of  joint  after  joint. 

Gout  differs  from  rheumatoid  arthritis  by  the  presence  of  deposits 
of  urate  of  sodium  in  the  joints,  the  ears,  tips  of  fingers,  and  the 
bursse  over  the  olecranon  process  of  the  elbow,  the  presence  of  uric 
acid  in  the  blood,  and  the  decided  history  of  acute  paroxysms. 

Gonorrhccal  r/ieutnatisvi,  so-called,  has  symptoms  akin  to  rheu- 
matoid arthritis,  but  the  history  of  urethral  suppuration  clears  up  the 
diagnosis. 

Paralysis  agitans,  when  pronounced,  might  be  confounded  with 
rheumatoid  arthritis  if  the  examination  were  limited  to  the  joints; 
but  the  whole  history,  such  as  the  tremor,  the  gait,  etc.,  should  pre- 
vent error. 

F^rognosis.  If  early  treatment  be  instituted,  the  disease  may  be 
held  in  abeyance  for  several  years.  After  pronounced  structural 
changes  have  begun,  the  malady  is  incurable,  although  it  may 
remain  stationary  for  a  long  time. 

Treatment.  If  treatment  be  instituted  before  serious  structural 
lesions  have  occurred,  the  author  has  seen  benefit  in  many  cases  by 
the  following  plan  :  Oleian  viorrhuce  carefully  and  thoroughly  rubbed 
into  the  affected  joints  three  times  a  day,  with  the  internal  use  oi lithii 
citras  effervescentes,  3j  (4  Gm.),  three  times  a  day,  and  the  following 
tonic  mixture : 

R.     MasscE  ferri  carbonat. gr.  v  .3  Gm. 

Liquor,  potass,  arsenit.,     ....    Tt\^v  .3  Cc. 

Vini  xerici,      {t^']  4.  Cc. 

Aquffi  distill., fjj  4.  Cc. 

After  meals,  well  diluted. 

I  have  had  some  success  from  painting  the  joints  when  painful 
with  the  following  combination,  using  at  the  same  time  guaiacol 
carbonat.,  gr.  v-x  (0.3-0.6  Gm.),  three  times  daily: 

R  .     Guaiacol, i  part 

Tinct.  iodi, 6  parts.  M. 

Sig. — Paint  over  joints  twice  daily. 


ACUTE  GENERAL   DISEASES.  229 

Complete  recoveries  are  reported  from  the  long-continued  adminis- 
tration of  small  doses  of  liquor  potassii  arsenitis. 

Attention  to  diet  and  hygiene  are  most  important  and  valuable. 
When  structural  changes  have  destroyed  portions  of  the  joint,  pallia- 
tive treatment  is  the  chief  indication. 


GOUT. 

Synon3rms.  Podagra,  gout  in  the  foot ;  chiragra,  the  hand ; 
gonagra,  the  knee. 

Definition.  A  constitutional  disease,  usually  inherited  ;  charac- 
terized by  the  sudden  occurrence  of  a  paroxysm  of  severe  pain  and 
swelling  in  one  of  the  smaller  joints, — the  great  toe  usually, — with  the 
presence  of  uric  acid  in  the  blood,  and  the  deposit  of  the  urate  of 
sodium  in  the  structure  of  the  joint. 

Causes.  Predisposing :  inherited,  male  more  than  female — 
women  after  menopause. 

Exciting;  malt  liquor  and  wine  drinking;  large  consumption  of 
animal  food ;  lead  poisoning ;  winter  season. 

When  an  inherited  tendency,  may  begin  early  in  life ;  when  an 
acquired  tendency,  after  thirty-five  years. 

The  pathological  cause  consists  in  the  presence  of  an  excess  of  uric 
acid  in  the  blood  in  the  form  of  urate  of  sodiu??i. 

Pathological  Anatomy.  Gout  is  characterized  by  the  deposit 
o{  urate  of  sodiutn  from  the  blood  into  the  structure  of  joints  and 
tissues  that  are  not  very  vascular.  The  deposit  is  associated  with 
signs  of  inflammation — to  wit :  hyperaemia,  redness  of  the  surface, 
with  swelling  and  effusion  in  and  around  the  affected  joint.  The 
surfaces  of  the  joint  are  incrusted  with  chalk-like  masses,  consisting 
of  urates,  which  become  greater  with  each  attack,  finally  causing 
great  deformity. 

The  deposit  usually  begins  in  the  metatarso-phalangeal  joint  of  the 
great  toe,  but  other  and  many  joints  are  soon  affected. 

The  deposits  may  also  be  found  in  the  knuckles,  eyelids,  and  car- 
tilages of  the  ear. 

"  Crystals  of  urate  of  soda  are  deposited  in  the  tubules  and  intra- 
tubular  tissues  "  of  the  kidneys — "  gouty  kidney  " — and  may  be  seen 
by  the  naked  eye,  the  kidneys  becoming  small,  granular,  and  fibrous. 


230  PRACTICE    OF    MEDICINE. 

Hypertrophy  of  the  left  ventricle  and  of  the  arteries,  ending  in 
atheromatous  changes,  are  results  of  gout. 

Symptoms,  ylcute  gout  is  rare  in  the  United  States.  It  occurs 
in  paroxysms;  one  year's  interval  between  the  first  and  second 
attack  ;  six  months  usually  between  the  second  and  third,  after  which 
it  may  occur  at  any  time. 

Prodromes  usually  precede  the  paroxysm  for  several  days,  to  wit, 
acid  dyspepsia,  constipation,  headache,  and  lassitude. 

The  paroxyvn'\)t^\x\s  suddenly,  between  midnight  and  2  A.  M., 
with  acute  pain  in  the  ball  of  the  great  toe,  which  becomes  red,  hot, 
sivolU-n,  and  so  sensitive  that  the  slightest  touch  cannot  be  borne. 

The  veins  are  filled,  the  foot,  ankle,  and  leg  swollen,  and  the  limb 
the  seat  of  sudden  spasmodic  contractions,  which  increase  the  suffer- 
ing ;  slight  relief  is  afforded  by  elevating  the  limb.  Associated  with 
the  local  symptoms  are  cJiill,  fever,  quickened  pulse,  thirst,  coated 
tongue,  constipation,  and  scanty,  acid,  high-colored  urine,  which  de- 
posits, on  cooling,  a  heavy  ^r^V/v/z/^i/ sediment. 

Towards  daylight  the  symptoms  ameliorate,  to  return  again  at  sun- 
down, the  severity  gradually  lessening,  until  the  fourth  or  fifth  day, 
when  convalescence  is  established,  the  patient,  as  a  rule,  feeling  better 
than  before  the  attack. 

Chronic  Gout.  Either  the  result  of  acute  attacks  or  with  a  greater 
number  of  joints  being  attacked. 

The  paroxysms  occur  at  any  time,  but  develop  slowly,  with  less 
pronounced  local  and  general  symptoms.  Deposits  are  noticed,  the 
joints  becoming  hard,  knobby,  and  often  distorted.  The  deposits  or 
chalk  stones  (urate  of  sodium)  occur  about  the  joints,  tendons,  and 
bursjE,  and  helix  of  the  ear. 

Diagnosis.  An  error  cannot  occur  if  the  history  of  the  case  can 
be  obtained,  to  wit :  hereditary  tendency,  age,  sex  (females  rare,  until 
menopause),  mode  of  living,  character  of  symptoms,  and  presence  of 
the  characteristic  deposits. 

Prognosis.  Acute  gout  rarely  fatal ;  is  prone  to  return,  but  much 
depending  upon  the  mode  of  living. 

Chronic  gout  decidedly  shortens  life.  The  most  serious  signs  are 
those  indicating  advanced  renal  disease,  with  non-elimination  of  uric 
acid.  Gout  influences  unfavorably  the  prognosis  from  acute  diseases 
or  injuries. 

Treatment.     For  the  acute  paroxysms,  at  once,  vinutn  colchici 


ACUTE   GENERAL   DISEASES.  231 

radicis,  gtt.  xv-xx-xxx  (1-1.3-2  Cc),  every  two  hours,  ivell  diluted, 
either  alone  or  in  combination  with  a. potassitcni  salt,  or  sodiisalicylas, 
gr.  XX  (1.3  Gm.),  every  two  to  four  hours,  well  diluted,  until  relief  or 
ringing  in  the  ears  occurs.  While  the  acute  symptoms  of  gout  are 
not  so  rapidly  relieved  by  sodii  salicylas  as  are  those  of  acute  rheu- 
matism, still  it  is  an  invaluable  remedy  and  is  rapidly  succeeding 
colchicum.  After  the  decrease  of  the  acute  symptoms,  lessen  the 
dose,  but  continue  the  remedy  for  some  time. 
Dr.  Bartholow  recommends  the  following  pill :    • 

B:.     Colchicinse, g^-  Tff  •  -0013  Gm. 

Ext  colocynth.  comp., gr-  ss  .032    Gm. 

Quininse  sulph., gr.  iij  .2        Gm.        M. 

Every  two  or  three  hours. 

For  the  pam,  hypodermic  injection  of  morphince  sulphas,  and 
wrapping  the  intlamed  joint  in  cotton-wool  saturated  with  liq.  pliwib. 
subacetat.  dil.  and  tinciura  opii.  The  use  of  morphia  in  acute  gout 
must  be  with  caution,  as  many  subjects  have  more  or  less  contracted 
kidneys. 

The  diet  must  be  restricted  to  milk  and  non-acid  fruits,  raw  or 
cooked.  The  drinking  of  several  ounces  of  water,  hot  or  natural, 
every  three  hours,  is  most  useful. 

For  subacute  or  lingering  cases,  and  in  chronic  gout,  potassii  iodi- 
dwn  is  valuable. 

JJ .     Potassii  iodidi, ^ij  8.  Gm. 

Vini  colchici  radicis, f^i''  ^5-  Cc. 

Aquae  destil., f^iiss  75.  Cc.  M. 

SiG. — Teaspoonful,  well  diluted,  after  meals  and  at  bedtime. 

Y  ox  chronic  gout,  regulated  diet,  free  action  on  the  secretions,  and 
lithii  citras  efferuescentes,  Z]  (4  Gm.),  three  or  four  times  a  day,  well 
diluted  with  water ;  and  perhaps  a  course  of  quinina,  ferrum,  and 
arsenicum. 

To  prevent  paroxysm,  keep  secretions  acting  by  the  free  use  of 
pure  water  or  a  good  alkaline  water,  such  as  Buffalo  lithia  or  Farm- 
ville  lithia  water,  or  Saratoga  Vichy. 

The  diet  is  of  the  greatest  importance,  and  should  consist  chiefly 
of  vegetables  and  fruit,  excepting  tomatoes  and  strawberries,  lemons 
and  oranges ;  fresh  meat  must  be  discontinued  for  a  time ;  oysters, 
fish,  and  soups  may  be  used  sparingly.     Alcoholic  and  malt  liquors 


232  PRACTICE   OF    MEDICINE. 

are  contraindicated,  as  are  tea  and  coffee  ;  inilk  should  replace  all 
the  above.  No  eggs  or  dishes  containing  eggs ;  no  pastry,  hot  bread, 
or  cakes;  no  sweetmeats,  spices,  or  condiments. 

Systematic  exercise,  especially  walking,  is  of  great  advantage. 

Cold  bathing  with  caution,  while  the  vapor  or  Turkish  baths  are 
of  benefit. 

Changing  from  a  cold  to  a  warm  climate  in  winter,  and  the  use  of 
flannel  underclothing,  are  strongly  recommended. 

DIABETES  MELLITUS. 

Synonyms.     Glycosuria ;  melituria. 

Definition.  A  chronic  affection  characterized  by  the  constant 
presence  of  grape  sugar  in  the  urine,  an  excessive  urinary  discharge, 
and  the  progressive  loss  of  flesh  and  strength. 

Causes.  Most  common  in  males.  More  frequent  in  the  Hebrew 
than  the  Christian.  Rare  in  negroes.  Occurs  at  all  ages,  but  most 
frequently  between  twenty-five  and  fifty  years.  It  is  often  hereditary. 
Disorders  of  the  nervous,  hepatic,  and  renal  systems.  Excessive  use 
of  farinaceous  food  and  malt  liquors.     Sexual  excesses. 

The  tx^ct  pathology  of  diabetes  mellitus  differs  in  different  cases, 
and  in  the  present  state  of  knowledge  no  exclusive  view  can  be 
adopted.  Still,  there  are  reasons  for  believing  that,  in  a  large  pro- 
portion of  cases,  the  nervous  system  is  primarily  at  fault,  though  the 
character  of  the  lesions  may  differ.  Pavy  believes  diabetes  mellitus 
originates  in  the  nervous  system,  and  probably  as  a  vaso-motor 
paralysis.  Disease  or  extirpation  of  the  pancreas  is  followed  by 
diabetes,  and  it  is  claimed  the  pancreas  secretes  a  glycolytic  ferment. 

Patholo^cal  Anatomy.  None  peculiar  to  diabetes  is  yet 
recognized. 

Hyperaemia  and  hypertrophy  of  the  liver  and  kidneys  are  gener- 
ally present,  the  result  of  increased  functional  activity.  Various 
organic  changes  are  found  in  the  pancreas. 

The  changes  in  the  lungs  peculiar  to  phthisis  are  often  found  in 
very  chronic  cases. 

The  changes  in  the  nervous  system  are  not  fully  determined. 

Symptoms.  Clinically,  cases  differ  greatly  in  their  course  and 
severity  ;  one  class  presenting  slight  symptoms  and  a  chronic  course; 
another  class  having  marked  local  and  constitutional  symptoms  and 


ACUTE   GENERAL   DISEASES.  233 

running  an  acute  course.  The  symptoms  of  a  typical  case  may  be 
arranged  under  the  following  heads  : 

Urinary  Orgajis  and  Urine.  Micturition  more  frequent  and  the 
tirine  increased  \n.  quantity.     Pain  over  the  region  of  the  kidneys. 

The  quantity  of  urine  may  amount  to  4,  8,  12,  20,  or  30  pints  in 
twenty-four  hours.  It  is  usually  pale,  clear,  and  watery,  having  a 
sweetish  taste  and  odor,  the  specific  gravity  ranging  from  1.025  to 
I  050.  It  ferments  rapidly  if  kept  in  a  warm  place.  It  yields  grape 
sugar  to  the  usual  tests,  the  amount  present  varying  from  an  ounce  to 
two  poujids  in  the  twenty-four  hours. 

The  urea  and  uric  acid  are  increased.     Albumin  may  be  present. 

The  increased  passage  of  a  large  quantity  of  saccharine  urine  causes 
a  constant  itching,  burning,  and  uneasy  sensation  at  the  prepuce, 
along  the  urethra,  and  at  the  neck  of  the  bladder;  in  females,  itching 
and  eczema  of  the  vulva  are  common  ;  in  children,  incontinence  of 
urine  is  frequent. 

Digestive  Organs.  An  almost  constant  symptom  is  thirst,  with  a 
dry  and  parched  condition  of  the  mouth.  At  times  the  appetite  is 
excessive,  again  absent.  The  breath  may  have  a  sweetish  odor,  the 
tongue  irritable,  red,  and  often  cracked.  Dyspeptic  symptoms  are 
common,  and  occasionally  vomiting.  The  bowels  are  constipated, 
the  stools  pale  and  dry.     At  times  diarrhoea  may  occur. 

The  patient  complains  of  feeling  very  weak,  languid,  and  of  S07'e- 
ness  and  pain  in  the  limbs  ;  there  is  more  or  less  etnaciation,  a  harsh, 
dry  skin,  the  countenance  distressed  and  worn. 

The  mind  is  often  greatly  altered  ;  depression  of  spirits,  decline  in 
firmness  of  character  and  moral  tone,  with  irritability,  are  present. 
Sexual  inclination  and  power  are  greatly  diminished.  Defects  of 
vision  are  present. 

The  blood  and  various  secretions  cotttain  sugar. 

Complications.  Pulmonary  phthisis  ;  Bright's  disease  ;  defects 
of  vision  from  atrophy  of  the  retina  or  the  formation  of  a  soft  cataract ; 
boils  and  carbuncles,  and  chronic  skin  affections,  such  as  psoriasis 
and  eczema. 

Course.  The  clinical  history  varies  in  different  cases.  In  the 
majority  of  instances  the  course  is  chronic,  lasting  for  years,  the 
symptoms  beginning  insidiously,  and  becoming  progressively  worse, 
with,  at  times,  decided  remissions.  Occasionally  the  disease  runs  an 
acute  course,  death  occurring  within  four  or  five  weeks. 


234  I'RACTICE    OF    MEDICINE. 

Termination.  The  majority  of  cases  ultimately  prove  fatal,  the 
symptoms  markedly  changing,  the  urine  and  sugar  diminishing  \x\ 
quantity,  the  occurrence  of  albuminuria,  disgust  for  food  and  drink, 
and  the  development  of  hectic  fever  and  colliquative  diarrhoea. 

The  fatal  result  usually  arises  (rom  gradual  ex/iauslion  from  blood- 
poisoning,  leading  to  stumor,  ending  in  complete  coma,  or  occasionally 
io  delirium  or  convulsions,  or  from  complications. 

Rarely  death  occurs  suddenly  from  urcemic  convulsions  or  uraniic 
coma. 

Diagnosis.  Diabetes  mellitus  only  exists  when  grape  sugar  is 
permanently  present  in  the  urine.  "  It  is  not  the  quantity,  but  the 
persistence  of  sugar  which  constitutes  diabetes." 

With  grape  sugar  in  the  urine,  associated  with  more  or  less  in- 
crease in  the  urinary  flow,  it  should  be  mistaken  for  no  other  affection. 

From  Bright' s  disease,  by  the  absence  of  dropsy,  and  of  tube  casts 
in  the  urine,  and  the  constant  presence  of  sugar  in  the  urine  ;  but  the 
amount  of  albumin  in  the  urine  is  never  so  great  or  constant  in  dia- 
betes mellitus  as  in  Bright's  disease. 

From  diabetes  insipidus,  by  the  absence  of  sugar  in  the  blood  and 
urine,  and  the  larger  quantity  of  urine  voided  in  polyuria. 

Simple  glycosuria  differs  from  diabetic  glycosuria  in  that  the 
amount  of  sugar  in  the  urine  is  not  constant, — at  one  time  being  pres- 
ent, at  another  absent, — the  amount  of  urine  voided  is  never  in  excess 
of  health;  simple  glycosuria  is  a  disease  of  the  aged;  diabetic  glyco- 
suria usually  appears  under  fifty  years.  Simple  glycosuria  often 
results  from  the  inhalation  of  chloroform,  the  excessive  use  of  chloral, 
and  in  the  insane,  also  from  excitement,  or  as  one  of  the  results  of 
injuries  to  the  head. 

Prognosis.  Most  unfavorable  as  regards  a  cure,  it  being  fairly 
questionable  if  complete  recovery  has  ever  occurred  in  a  typical  case. 
Still,  decided  amelioration  may  take  place  in  the  symptoms,  and  the 
progress  of  the  malady  be  greatly  retarded.  The  younger  the  patient, 
the  more  rapid  the  fatal  termination. 

Treatment.  Impress  upon  patients  the  importance  of  a  strictly 
regulated  diet.  Prohibit  or  restrict  the  consumption  of  such  articles 
as  contain  sugar  or  starch,  especially  ordinary  bread  or  flour,  sugar, 
honey,  potatoes,  peas,  beans,  rice,  arrowroot,  cracked  wheat,  oat- 
meal, turnips,  beets,  corn,  and  carrot?,  prunes,  grapes,  figs,  bananas, 
pears,  apples,  and  liquors  of  all  kinds,  whether  distilled  or  fermented. 


ACUTE  GENERAL   DISEASES.  235 

The  main  diet  should  be  of  animal  food,  including  meat,  poultry, 
game,  and  fish. 

A  moderate  amount  of  fluids  should  be  allowed,  and  in  a  majority  oi 
cases  milk  will  prove  beneficial,  although,  theoretically,  contraindi- 
cated.  Tea,  coffee,  and  cocoa,  without  sugar,  may  be  allowed  in  moder- 
ation, glycerin  or  saccharin  being  used  as  a  substitute  for  the  sugar. 

Regulated  exercise  is  of  importance.  The  patient  should  wear 
flannel,  and  have  two  or  three  warm  baths  every  week,  or  an  occa- 
sional Turkish  bath. 

Therapeutical  treatment.  It  is  difficult  to  estimate  correctly  the 
action  of  any  drug  in  this  disease,  for,  as  is  well  known,  a  proper  modi- 
fication of  the  diet  will  alone  produce  the  most  marked  improvement. 

Opium  exercises  an  influence  over  the  excretion  of  sugar,  but  the 
effect  is  not  always  maintained.  Pavy  strongly  urges  the  use  of 
codeina  in  doses  of  gr.  ss-iij  (0.032-0.2  Gm.),  three  times  a  day, 
gradually  increased.  The  use  of  morphines  hydrochloras,  gr.  j  (0.065 
Gm.),  daily,  or  pulvis  opii,  gr.  iij-v  (0.2-0.3  Gm.),  daily,  is  a  favorite 
prescription.  Prof.  Da  Costa  suggests  the  use  of  ergota,  which  has 
decreased  the  urinary  discharge  and  the  quantity  of  sugar  in  a  number 
of  cases.  Prof.  Bartholow  has  met  with  an  apparent  cure  by  ammonii 
carbonas.  Uranii  nitras,  gr.  iij  (0.2  Gm.),  three  times  daily,  will 
often  markedly  reduce  the  urine  and  sugar,  and  sodii  salicylas,  gr.  xv 
(l  Gm.),  three  times  daily,  will  markedly  control  the  formation  of 
sugar.  Liquor  bromini  arsenitis,  TTLiij-v  (0.2-0.3  Cc),  three  times  a 
day,  often  gives  good  results.  Dickinson  remarks  that  "  strychnina  is, 
of  all  remedies,  the  most  constantly  useful."  Potassii  bromidum,  3j 
(4  Gm.)  during  the  twenty-four  hours,  is  strongly  urged.  The  fol- 
lowing remedies  are  recommended  by  different  observers — to  wit: 
pepsi7ium,  liquor  potassii  arsenitis,  iodum,  potassii  iodidum,  acidum 
lacticum,  glycerinum,  quinina,  and  tinctura  cannabis  indices.  Cures 
are  reported  from  pulvis  j'ambul  seeds,  gr.  v-x  (0.3-0.6  Gm.),  three 
times  daily.  Also  methylene  blue,  gr.  viij  (0.52  Gm.),  per  diem.  The 
evidence  in  favor  of  the  majority  of  these  drugs  is  far  from  satisfactory. 

For  diabetic  cotna,  alkalies  are  particularly  indicated.  Sodium 
carbonas  subcutaneously,  or  by  intravenous  injection,  watching 
closely  the  effect  on  pulse  and  heart,  as  recommended  by  Stabel- 
man.  The  use  of  large  quantities  (quarts)  of  the  normal  salt  solution 
by  means  of  hypodermoclysis,  and  slowly  thrown  into  the  large  bowel, 
is  a  most  valuable  aid  to  elimination.  Use  also  inhalations  of  oxygen 
and  diuretics  and  fluids  to  promote  elimination  of  toxic  products. 


236  PRACTICE    OF    MEDICINE. 

Symptomatic  treatment  is  mostly  called  for.  For  emaciation  and 
zx\7K.m\'x,  fcrrum  and  oleum  morrhua;  ;  for  sleeplessness  and  restless- 
ness, viorphina  sulphas,  potassii  bromutum,  chloral,  or  hyoscina 
hydrobromas.  For  boils  and  carbuncles,  r(^?A7V57/'/^/^/V/«w.  Duchenne 
suggests  the  following  solution  for  the  excessive  thirst  of  diabetic 
patients : 

R  .      Potassii  phosphat. two  parts. 

Aquce seventy-five  parts. 

SiG. — One  teaspoonful  twice  or  thrice  daily,  in  wine  or  hop  tea. 

The  dyspepsia  and  lung  symptoms  must  be  managed  on  general 
principles. 

The  constant  _^a/z/<7«/V  current  \vx'=,  been  productive  of  good  results. 
A  change  of  scene  and  air  is  beneficial. 

Surgical  operations  should  on  no  account  be  undertaken  on  diabetic 
patients. 


DIABETES  INSIPIDUS. 

Synonyms.     Polyuria;  polydipsia. 

Definition.  An  affection  characterized  by  the  excessive  secretion 
of  a  very  large  quantity  of  pale,  watery  urine,  free  from  albumin  and 
sugar. 

Causes.  Occasionally  hereditary,  or  diabetes  mellitus  may  have 
existed  in  the  parent;  more  common  in  children  or  young  adults; 
men  are  more  liable  than  women  ;  injuries  and  diseases  of  the  ner- 
vous system ;  hysteria ;  exposure  to  cold  ;  drinking  freely  of  cold 
water;  fatigue;  prolonged  debility ;  malaria;  syphilis. 

The  probable  immediate  cause  of  the  excessive  secretion  of  urine 
consists  in  dilatation  of  the  renal  vessels,  the  result  of  paralysis  of 
their  muscular  coat,  caused  by  derangement  of  innervation,  as  the 
condition  can  be  induced  experimentally  by  irritating  a  spot  in  the 
fourth  ventricle,  or  by  section  of  portions  of  the  sympathetic  nerve. 

Symptoms.  The  affection  is  characterized  by  ^^r^a/ ///;W/,  with 
an  increased  flow  of  pale,  watery,  slightly  acid  urine,  the  amount 
varying  from  one  to  five  or  six  gallons  in  the  twenty-four  hours.  The 
specific  gravity  ranges  from  i  001-1.007.  Sugar  and  albumin  are 
absent.  Urea  and  the  other  solids  are  increased.  The  appetite  is 
voracious,  the  bowels  are  obstinately  constipated,  and  the  skin  is  dry 
and  harsh. 


ACUTE   GENERAL    DISEASES.  237 

The  large  flow  of  urine  is  usually  preceded  by  various  nervous 
phenomena,  as  nervousness,  irritability ,  inability  to  concentrate  the 
mind,  vivid  imagination,  a  failure  of  memory,  and  headache. 

Unless  the  affection  is  soon  arrested,  great  loss  of  flesh  and  strength 
result. 

Diagnosis.  It  differs  from  diabetes  mellitus  by  the  absence  of 
grape  sugar  in  the  urine. 

From  paroxysmal  diuresis,  by  the  absence  of  the  increased  urine 
permanently. 

From  interstitial  nephritis,  by  the  greater  amount  of  urinary  dis- 
charge and  the  absence  of  albumin,  oedema,  and  casts,  and  the 
cardiac  and  vessel  changes. 

Prognosis.  Rather  unfavorable  as  to  a  radical  cure,  unless  caused 
by  syphilis.  Death  rarely  is  due  to  the  diabetes,  but  to  some  inter- 
current malady  that  the  patient  has  been  unable  to  withstand,  on 
account  of  the  weakness  produced  by  the  diabetes. 

Treatment.  If  due  to  syphilis,  potassii  iodiduin  and  hydrargyrum 
are  of  real  benefit.  Prof.  Da  Costa  has  had  success  with  ergota  in  the 
form  of  the  fluid  extract  or  the  aqueous  extract.  Pilocarpus  has  been 
used  with  success.  Prof.  Bartholow  recommends  galvanism  in  cases 
not  cured  by  potassii  iodidum,  placing  "one  electrode  to  the  neck 
below  the  occiput,  the  other  to  the  hypochondriac  region  in  turn." 
Valerian, potassii  bromidum,  and  sodii  salicylas  have  been  used.  The 
author  has  effected  a  cure  in  three  cases,  where  other  remedies  had 
failed,  by  the  use,  internally,  of — 

K.      Strychninse  sulphatis, gr.  ^-^  .0015  Gm. 

Acid,  hydrochlor.  dil., TT^x  .6         Cc. 

AquEe  lauro-cerasi, f^ij  8.           Cc.         M. 

Well  diluted. 

The  obstinate  constipation  is  best  overcome  \i^  pilules  cathartic ce 
compositcE,  one  at  bedtime. 

LITH^MIA. 

Synonyms.  Lithiasis  ;  uric  acid  diathesis  ;  uricaemia;  American 
gout. 

Definition.  A  condition  to  which  the  fluids  of  the  body  are  satu- 
rated with  nitrogenized  waste,  in  the  form  of  lithic  or  uric  acid ; 
characterized  by  marked  dyspepsia,  various   nervous   phenomena, 


238  IKACTICE    OF    MliDlCIM-:. 

muscular  and  arliiular  pains,  bronchial  catarrh,  all  or  any  of  these 
associated  with  scanty,  high-colored,  acid  urine. 

Causes.  High  living,  with  little  exercise;  imperfect  digestion  of 
nitrogenized  food;  impaired  elimination  of  uric  acid.  The  direct  or 
remote  offspring  of  the  gouty  are  most  frequently  the  victims. 

Pathology.  Not  yet  clearly  determined.  Tlie  non-elimination 
of  certain  products  which  have  a  deleterious  influence  upon  the 
nervous  system.  That  uric  acid  does  exist  in  the  blood  is  now  gen- 
erally accepted. 

Symptoms.  Those  of  dyspepsia,  associated  with  irregular 
bowels,  scanty,  high-colored,  acid  urine,  sp.  gr.  i. 024-1. 028,  contain- 
ing neither  sugar  nor  albumin,  but  showing  an  increased  proportion 
of  urates  or  uric  acid,  or  both,  and  oxalate  crystals.  Also  depressed 
spirits,  impaired  memory,  loss  of  interest  in  occupation,  sleepless  nights, 
attacks  of  vertigo,  neuralgic  pains  in  the  head,  and  a  constant  dread 
of  apoplexy  or  cerebral  disease.  Also  pains  in  the  joints,  neuralgic  in 
character,  and  in  the  dorso-lumbar  region  and  right  scapular  region. 

If  the  condition  be  allowed  to  continue,  the  following  organic 
changes  may  result — to  wit :  fatty  heart ;  fibroid  kidney  ;  enlarged 
liver,  or  changes  in  the  cerebral  vessels. 

Diagnosis.  From  gout,  by  the  absence  of  acute  paroxysms  and 
resulting  changes  in  the  joints. 

Prognosis.  If  properly  recognized  and  treated,  complete  recov- 
ery will  result,  although  it  is  a  disorder  of  long  duration. 

If  not  properly  treated,  develops  some  one  of  the  organic  diseases 
mentioned. 

Treatment.  Regulated  diet,  using  fresh  meat  once  daily,  poultry, 
game  (plainly  cooked),  fresh  fish,  oysters,  occasionally  eggs,  lettuce, 
spinach,  celery,  cold  slaw,  and  tomatoes;  avoid  all  kinds  of  starchy 
and  saccharine  foods,  also  all  stimulants,  tea  and  coffee,  using  milk, 
skimmed  milk,  or  milk  and  cream.  Act  freely  on  all  the  secretions, 
particularly  the  liver  and  kidneys.  Systematic  exercise.  Avoid 
tonics,  bromides,  chloral,  and  opium.  Long  course  of  alkaline  waters, 
particularly  the  lithia  waters.  Intestinal  antiseptics  are  valuable,  such 
as  salol,  gr.  j  (0.065  Gm.)  three  times  daily,  or  potassii  permanganas, 
gr.  j  (0.065  Gm.)  in  coated  pills  after  meals.  Good  results  follow 
lithiicitras,  gr.  xx  (1.3  Gm.),  t.  d.,  sodii phosphas,  gr.  xxx-lx  (2-4  Gm  ), 
ter  die,  or  acidiim  benzoicutn,  gr.  x  (0.6  Gm.),  t.  d.,  all  well  diluted 
with  water.     One  of  the  very  best  drugs  is  acidum  nitricum  dilutum. 


ACUTE  GENERAL   DISEASES.  239 

vr^x  (0.6  Cc.)  in  half  a  glass  of  water,  four  times  a  day,  with  the  occa- 
sional use  of  pihdcB  rhei  composiia  at  bedtime.  Considerable  success 
has  been  obtained  with  piperazine ,  gr.  x-xv  (0.6-1  Gm.)  in  solution, 
after  meals.     Strontium  has  acted  nicely  in  several  cases. 

R .     StroQtii  bromidi  purse, gr.  xxx  2.  Gm. 

Glycerini, TTLxxx  2.  Cc. 

Infus.  gentianae, fjiss  6.  Cc.  M. 

SiG. — Before  meals,  well  diluted. 

CHOLERA. 

Synonyms.  Epidemic  cholera ;  Asiatic  cholera ;  malignant 
cholera ;  spasmodic  cholera. 

Definition.  An  acute,  specific,  infectious  disease,  epidemic  in  the 
majority  of,  although  endemic  in  other,  localities ;  characterized  by 
the  transudation  of  serum  into  the  stomach  and  intestinal  canal,  and 
violent  purging  of  a  peculiar,  rice-water-like  fluid,  the  persistent  vomit- 
ing of  a  similar  material,  severe  muscular  cramps,  and  a  condition  of 
prostration,  followed  by  collapse  and  death,  or  of  a  reaction  from  the 
collapse  and  the  development  of  the  typhoid  state  {cholera  typhoid'). 

Causes.  A  specific  poison,  the  "comma  bacillus"  of  Koch. 
Cholera  is  but  feebly  contagious,  in  the  usual  acceptation  of  that 
word,  but  it  is  unquestionably  ififectious. 

The  evidence  seems  conclusive  that  the  cholera  stools  are  the  main, 
if  not  the  only,  channel  of  infection,  and  that  the  great  cause  of  the 
propagation  of  cholera  is  the  contamination,  with  the  cholera  stools,  ■ 
of  the  water  used  for  drinking  purposes.  Milk  may  also  be  the 
vehicle  by  which  it  spreads.  It  is  claimed  that  the  bacillus  is  inert 
in  the  intestinal  canal  unless  the  individual  is  in  the  "  receptive 
state" — that  is,  a  condition  of  intestinal  catarrh,  such  as  results  from 
eating  unripe  fruit,  beer  and  spirit  drinking,  and  indigestible  food. 
It  is  also  determined  that  the  bacilli  are  destroyed  by  acids,  and  that 
if  the  stomach  be  normal,  cholera  will  not  result.  "With  pure 
water,  pure  air,  pure  soil,  and  pure  habits,  cholera  need  not  be 
feared."     (Hart.) 

Little,  if  any,  danger  exists  from  being  in  the  presence  of  the 
affected,  although  the  emanations  from  the  cholera  excreta  in  the 
atmosphere  may  generate  the  disease  if  swallowed  or  inhaled.  The 
dead  bodies  of  cholera  subjects  apparently  possess  slight  infective 
property,  "the  bacteria  of  composition"  probably  destroying  the 
cholera  germs.  One  attack  does  not  afford  protection  against  another. 


240  PRACTICE    OF    MKIMCINE. 

The  pc-riod  of  incubaiion  is  short,  under  .1  week,  usually. 

Pathological  Anatomy.  This  is,  as  yet,  far  from  satisfactory. 
The  morbid  appearances  in  the  majority  of  cases  of  death  from  chol- 
era may  be  thus  summarized.  The  temperature  generally  rises  after 
death,  the  body  remaining  warm  for  a  considerable  time.  Rigor 
mortis  rapidly  ensues,  the  muscular  contractions  being  often  so  pow- 
erful as  to  displace  and  distort  the  limbs.  The  skin  is  mottled  and 
the  body  greatly  shrunken.  The  blood  is  darker  in  color,  thick, 
viscid,  feebly  coagulable,  and  slightly  acid.  The  arteries  are  quite 
empty  of  blood ;  the  veins,  on  the  other  hand,  are  distended.  The 
organs  are,  as  a  rule,  pale  and  shrunken. 

The  stomach  and  intestinal  mucous  membranes  are  congested,  and 
present  evidence  of  extravasation  and  ecchymoses,  or  are  bleached 
and  pale.  The  stomach  and  intestines  usually  contain  a  quantity  of 
whey  like  material,  having  an  alkaline  reaction,  as  well  as  quantities 
of  cast-off  epithelium  and  the  bacillus.  It  is  thought  by  many  that 
the  stripping-off  of  the  epithelium  is  a  post-mortem  phenomenon. 
The  Peyer's  solitary  and  Brunner's  glands  are  usually  enlarged  and 
prominent,  and  occasionally  evidences  of  ulceration  are  apparent  in 
the  solitary  glands,  and  sections  placed  under  the  microscope  show 
the  "comma  bacillus."  The  villi  of  the  mucous  membrane,  as  well 
as  the  epithelium  of  the  small  intestines,  are  stripped  off,  leaving  the 
basement  membrane,  for  the  most  part,  exposed.  The  Ihter  is  more 
or  less  advanced  in  fatty  degeneration,  presenting  a  somewhat  mot- 
tled, yellowish  discoloration.  The  kidneys  are  congested,  the  epi- 
thelium of  the  tubules  granular,  and  detached  from  the  basement 
membrane,  blocking  up  the  tubes.  Prof.  Bartholow  observed,  in  all 
of  his  autopsies,  "considerable  hyperaemia  and  dilatation  of  the  ves- 
sels of  the  medulla  oblongata.  The  constancy  of  this  lesion  would 
seem  to  indicate  a  relationship  between  congestion  of  the  medulla 
and  the  cramps." 

Symptoms.  In  accordance  with  the  law  of  epidemic  infectious 
diseases,  the  onset,  course,  and  character  of  the  symptoms  vary  in 
different  cases  and  at  different  periods  in  the  same  epidemic. 

The  disease  may  either  set  in  suddenly  in  a  patient  previously  in 
good  health,  or  it  may  follow  an  attack  of  rather  severe  and  persistent 
diarrhoea,  with  pain,  nausea,  7>omiti}ig,  and  depression.  Such  cases 
are  termed  Cholerijie,  the  stools  of  which  are  infectious. 

In  a  typical  case  there  are  three  stages :  Jirst,  diarrhoea ;  second, 
prostration  ;  third,  collapse,  or,  in  favorable  cases,  reaction. 


ACUTE   GENERAL   DISEASES.  241 

First  Stage.  Begins  with  chilliness,  excessive  thirst,  coated  tongue, 
unpleasant  taste  in  the  mouth,  slight  abdominal  pain,  and  three  or 
four  copious,  watery,  yet  faecal  stools  during  the  day,  and  a  decided 
feeling  of  weakness,  the  stools  rapidly  becoming  whey-like,  easily 
voided,  but  with  force  and  only  slight  pain. 

Second  Stage.  The  stools  rapidly  increase  in  number,  are  voided 
with  a  rushing  force,  and  consist  of  many  quarts  of  grayish,  or  whitish, 
rice-water-like  fluid,  accompanied  with  forcible  vomiting,  first  of  the 
contents  of  the  stomach,  mixed  with  more  or  less  bilious  matter, 
afterward  of  the  peculiar  rice-water-like  material ;  thirst  becomes 
most  intense,  increasing  or  diminishing  with  the  variations  in  the 
number  of  the  vomiting  and  stools ;  severe  imiscular  cramps  soon 
follow,  most  severe  in  the  calves,  although  occurring  in  all  parts  of 
the  body. 

Third  Stage.  The  stools,  vomiting,  and  cramps  continue.  The 
appearance  of  the  patient  becomes  frightful ;  the  eyes  are  sunken 
and  surrounded  by  blackened  rings,  the  nose  pinched  and  pointed, 
the  cheeks  hollow,  and  the  lips  blue  (facies  cholerica) ;  the  surface 
cold  and  moistened  with  a  sticky  perspiration ;  the  skin  of  the  hands 
and.fingers  has  the  sodden  appearance  of  the  "  washerwoman  who 
has  washed  all  day,"  and  if  picked  up  in  folds,  the  fold  but  slowly 
disappears.  The  temperature  rapidly  falls,  the  pulse  becomes  small 
and  compressible,  barely  perceptible  at  the  wrist,  and  the  heart-beats 
are  scarcely  recognizable.  The  voice  is  weak,  husky,  and  sepulchral 
(vox  cholerica),  the  tongue  is  like  ice,  the  breath  is  cold  and  icy,  the 
urine  markedly  diminished  and  albuminous.  The  fnind  is  clear, 
but  most  patients  are  apathetic  and  indifferent  to  their  danger.  This, 
the  algid  state  of  cholera,  or  cholera  asphyxia,  usually  terminates  in 
death  in  from  three  to  twelve,  twenty-four,  or  forty-eight  hours,  but 
reaction  may  be  established. 

Stage  of  Reactioji.  The  temperature  of  the  body  rises,  the  pulse 
gradually  becomes  fuller  and  stronger,  the  countenance  becomes 
brighter,  the  stools  less  frequent  and  more  faecal,  the  vomiting  de- 
creases, the  thirst  lessens  ;  the  urine  increases  in  amount,  but  con- 
tinues albuminous,  the  patient  entering  a  slow  convalescence,  or 
typhoid  symptoms  develop,  the  so-called  cholera  typhoid,  which  pro- 
longs the  recovery  for  several  weeks. 

Convalescence  is  often  prolonged  and  complicated  by  thedevelop- 
ment  of  severe  bed-sores,  boils,  bronchitis,  pneumonia  or  parotitis, 
16 


242  PRACTICE    OF   MEDICINE. 

Sequelae.  Suppuration  of  the  parotid  gland  ;  painful  tetanic  con- 
traction of  the  flexor  muscles  of  the  limits;  abscesses  or  ulcers  of  the 
limbs ;  profuse  sweats ;  roseola,  erythema,  urticaria,  and  rarely  vesicu- 
lar eruptions. 

Diagnosis.  The  epidemic  character  and  rapid  spreading  and 
great  mortality  of  the  affection  prevents  its  being  mistaken  for  any 
other  disease,  although  isolated  cases  are  often  confounded  with 
cholerine  or  with  cholera  morbus,  the  points  of  distinction  being  few, 
unless  the  "comma  bacillus"  only  be  found  in  the  stools  of  true 
cholera. 

Prognosis.  Very  unfavorable,  the  mortality  ranging  from  twenty 
to  eighty  per  cent.  The  last  epidemic  in  this  country  was  much 
milder  than  former  ones.  The  prognosis  is  controlled  by  the  general 
condition  of  the  patient,  the  age,  habits,  and  the  development  of  the 
algid  state;  the  prognosis  being  more  favorable  in  those  cases  which 
develop  gradually  than  in  those  in  which  it  reaches  its  acme  at  a 
single  bound;  the  very  young  or  very  old,  those  addicted  to  the 
various  excesses  and  surrounded  by  unfavorable  hygienic  conditions, 
are  more  apt  to  perish  than  are  others. 

Treatment.  The  success  depends,  to  a  great  extent,  upon  its 
prompt  and  early  treatment,  for  experience  amply  attests  that  the 
arrest  of  the  disease  in  the  diarrhoeal  stage  is  comparatively  easy, 
and  in  the  stage  of  collapse  its  cure  is  altogether  an  exceptional 
occurrence;  therefore,  during  the  prevalence  of  cholera  the  mildest 
cases  of  diarrhoea  ought  to  receive  prompt  treatment,  for  many  cases 
have  their  beginning  as  a  mild  diarrhoea. 

It  must  not  be  overlooked  that  intelligent  nursing  and  regimen  are 
equally  as  important  as  medical  treatment. 

The  patient  should  be  put  to  bed  at  once,  and  all  food  withheld  for 
a  time  at  least.    Small  pellets  of  ice  may  be  allowed  instead  of  water. 

"  Of  all  the  remedies  proposed  for  the  arrest  of  the  diarrhoea,  not 
one  has  done  so  much  good  as  sulphuric  acid.  It  is  usual,  and 
generally  best,  to  combine  some  opium  with  it  (R.  Acid,  sulphuric, 
aromat.,  f^v  (20  Cc);  tinct.  opii  deodorat.,  f5iij(i2  Cc).  M.  SiG. — 
Ten  to  twenty  drops  every  hour  or  two  in  sufficient  water)."  (Bar- 
tholow.) 

Large  doses  of  bisjnuth  should  be  of  value  in  this  early  stage,  but 
opiwn  is  particularly  indicated,  preferably  in  the  form  of  morphina: 
sulphas,  hypodermically.    During  the  epidemics  of  i892-'93,  good  re- 


ACUTE  GENERAL   DISEASES.  243 

suits  were  reported  from  the  internal  use  of  hydrogen  peroxide,  f^ij 
(60  Cc),  with  aqua  destillata,  f^viij  (237  Cc),  in  cupful  doses  every 
two  hours.  Salol  and  plumbi  acetas  are  of  value  for  the  early- 
diarrhoea. 

Ziemssen  says :  '"  Calomel  has  the  first  place  of  all  drugs  which 
have  been  recommended  in  the  prodromal  stage.  Begin  with  two  or 
three  doses  of  gr.  vij  (0.45  Gm.),  followed  with  small  doses — gr.  ^ 
(0.048  Gm.) — every  two  hours." 

It  is  now  generally  admitted  that  as  the  first  symptoms  of  cholera 
are  those  of  intestinal  catarrh,  direct  medication  ought  to  be  of  the 
greatest  service.  This  is  done  by  etiteroclysis  or  irrigation  of  the 
canal  with  large  amounts,  from  one  to  three  gallons  twice  daily,  of 
hot  soaped  water,  hot  four  per  cent,  solutions  of  hydrogen  peroxide,  or 
weak  solutions  of  tannin,  or  hot  one  per  cent,  solutions  of  common  salt. 

The  enteroclysis  is  accomplished  by  means  of  a  soft  rubber  tube, 
one  metre  in  length  and  of  suitable  size,  to  be  introduced  into  the 
rectum,  in  front  of  the  promontory  of  the  sacrum,  into  and  up  through 
the  sigmoid  flexure  and  into  the  descending  colon.  This  tube,  which 
is  connected  with  a  reservoir,  should  not  be  too  small  nor  too  large, 
in  order  to  facilitate  its  introduction  through  the  folds  of  the  sigmoid 
portion  of  the  lower  bowel. 

In  fact,  the  greatest  difficulty  to  be  encountered  is  to  successfully 
pass  the  tube  in  front  of  the  promontory  of  the  sacrum,  and  enter  it 
into  the  sigmoid  flexure.  The  tube  should  be  of  proper  firmness  to 
prevent  it  from  bending  or  buckling  upon  itself  when  the  end  (which 
in  all  cases  should  be  rounded)  comes  in  contact  with  the  obstructing 
folds  of  the  intestine. 

For  the  distressing  vomiting,  lavage  of  stomach  with  hydrogen 
peroxide,  f^ij  (60  Cc.)  to  two  or  three  pints  of  hot  water,  or  iced  chain - 
pagne,  cocaine,  or  acidum  hydrocyatticum  may  sometimes  give  relief. 

Locally,  either  mustard  applications  to  the  abdomen  or  the  constant 
use  of  rubber  bags  filled  with  boiling  water. 

For  the  cramps,  hot  water  in  bottles,  hot  irons  or  bricks  applied 
over  painful  parts,  or  an  ointment  of  chloroform  or  chloral,  chloro- 
form or  ether  inhalations,  or  the  use  of  the  following  hypodermic 
solution,  strongly  recommended  by  Prof.  Bartholow  : 

R.     Chloral, giij  12.       Gm. 

Morphinas  sulph. , gr-  iv  .26  Gm. 

Aquse  lauro-cerasi, f|j  30,       Cc,             M. 

SiG. — Fifteen  to  thirty  minims  each  injection. 


244  PRACTICE    OF    MEDICINE. 

For  the  collapse,  heat  to  the  surface  and  the  free  use  o{  stimulants, 
or  spiriius  frumenti,  or  spiritus  vini gallici,  hypoderniically,  also  the 
hot  bath,  also  hypodennatoclysis  and  the  intravenous  injection  of 
saline  fluids  and  hypodermic  injections  of  strychninae  sulphas,  gr.  2V 
(0.003  Gm.).  Heat  is  of  the  greatest  value  in  all  stages  of  cholera, 
both  externally  as  very  hot  baths  (hot  air  or  hot  water),  and  hot  rectal 
injections. 

If  reaction  occur,  treat  indications  as  they  arise,  and  use  tonics, 
such  2is/erru)n,  quinina,  and  arsenicum. 

All  the  discharges  from  the  patient  should  be  thoroughly  disinfected 
as  soon  as  voided,  and  the  stools  and  vomited  material  buried. 


DISEASES   OF  THE  RESPIRATORY 
SYSTEM. 


PHYSICAL  DIAGNOSIS. 

Physical  Diagnosis  is  the  art  of  discriminating  disease  by 
means  of  the  eye,  the  ear,  and  the  touch. 

The  signs  thus  ascertained  are  connected  with  changes  or  altera- 
tions in  the  form,  density,  or  condition  of  the  structures  within,  and 
are  known  2i%  physical  signs. 

"  Physical  signs  are,  then,  the  exponents  of  physical  conditions,  and 
of  ?ioihing  more."     (Da  Costa.) 

The  methods  employed  in  the  physical  exploration  of  the  chest, 
are:  I,  Inspection;  II,  Palpation;  III,  Mensuration;  IV. 
Percussion;  V,  Auscultation;  M,  Succxission. 

Percussion  and  auscultation,  dealing  with  sounds,  are  of  the  great- 
est value  clinically. 

For  the  purpose  of  physical  exploration,  the  chest  is  mapped  ofif 
into  regions  or  divisions,  as  follows  : 

ANTERIORLY. 

First. — Supra-clavicular,  Lying  above  the  upper  edge  of  the 
clavicle,  usually  about  an  inch  in  extent. 


DISEASES   OF  THE   RESPIRATORY   SYSTEM,  245 

Second. —  Clavicular,  Corresponding  to  the  inner  two-thirds  of  the 
clavicle. 

Third. — Infra-clavicular ,  From  the  clavicle  to  the  lower  border  of 
the  third  rib. 

Fourth. — Mammary,  Between  the  third  and  sixth  ribs. 

Fifth. — Infra-mammary,  Downward  from  the  sixth  rib, 

LATERALLY. 

First. — Axillary,  That  portion  above  the  sixth  rib. 
Second. — Infra-axillary,  That  portion  below  the  sixth  rib. 

POSTERIORLY. 

First, — Suprascapular,  That  portion  above  the  scapula. 
Second. — Scapular,  That  portion  covered  by  the  scapula. 
Third. — Inter-scapular,  That  portion  between  the  scapulae. 
Fourth. — Infra-scapular,   That   portion  below  the    angle  of  the 
scapula. 

INSPECTION. 

Inspection  signifies  "the  act  of  looking."  Views  of  the  chest 
should  be  taken  from  the  sides  and  behind  as  well  as  from  the  front, 
for  which  purpose  a  good  light  should  be  obtained,  and  the  patient 
be  placed  in  as  easy  and  comfortable  a  position  as  is  possible. 

Inspection  reveals  the  form,  size,  color,  and  movements  of  the  chest, 
as  well  as  the  condition  of  the  superficial  pai-ts. 

In  health  the  sides  of  the  chest  are  for  the  most  part  symmetrical 
in  form,  size,  color,  and  movements,  both  sides  rising  equally  during 
the  act  of  inspiration,  and  falling  equally  during  the  act  of  expira- 
tion. During  the  act  of  inspiration  the  intercostal  spaces  in  the 
lower  two-thirds  of  the  chest  become  more  hollow,  as  also  do  the 
supra-clavicular  fossae. 

Inspij-ation  is  almost  entirely  the  result  of  muscular  action  ;  expira- 
tion, on  the  other  hand,  is  chieily  due  to  the  elasticity  of  the  lungs 
and  chest  walls,  aided  somewhat  in  forced  respiration  by  muscular 
action.  The  movement  of  inspiration  by  inspection  is  of  longer 
duration  than  that  of  expiration,  and  the  pause  between  the  acts  but 
momentary. 

The  respiratory  tnovement  is  visible  over  the  whole  thorax,  although 


246  PRACTICF.    OF   MEDICINE. 

in  males  and  in  children  it  is  most  distinct  at  the  lower  portion  (/«- 
ferior  costal  breathing),  while  in  the  female  it  is  most  distinct  at  the 
upper  portion  of  the  chest  {superior  costal  breathing). 


PALPATION. 

By  palpation  is  meant  the  application  of  the  palmar  surfaces  of 
the  hands  and  fingers  to  the  chest,  by  means  of  which  are  appre- 
ciated impressions  which  are  capable  of  being  conveyed  by  the 
sense  of  touch. 

The  objects  of  palpation  are  : 

First. — To  give  more  accurate  information  of  what  is  revealed 
by  inspection. 

Second. — To  locate  spots  of  soreness,  the  density  and  condition  of 
tumors,  if  any  be  present;  the  state  of  the  chest  walls,  the  frequency 
of  the  breathing,  and  the  action  of  the  heart. 

Third. — To  determine  the  existence  and  character  of  the  various 
kinds  oi  freviitus  (vibrations). 

By  fremitus  is  understood  certain  tactile  impressions  or  vibrations 
conveyed  to  the  surface  of  the  chest,  which  are  classed  and  produced 
as  follows : 

First. —  Vocal  fremitus,  produced  by  the  act  of  speaking  or  crying. 

Second. —  Tussive  fremitus,  produced  by  the  act  of  coughing;  of 
value  especially  when  the  voice  is  very  weak. 

Third. — Bronchial  fremitus,  produced  by  the  passage  of  air 
through  mucus,  blood,  or  pus,  in  the  bronchial  tubes,  during  the  act 
of  respiration. 

Fourth. — Frictio7i  fremitus,  produced  by  the  rubbing  together  of 
the  roughened  surfaces  of  the  pleura. 

When  the  normal  chest  vibrates  lightly,  it  is  termed  the  normal 
vocal freinitus. 

The  vocal frejnitus  is  more  distinct  upon  the  right  side  toward  the 
apex. 

If  the  lung  be  consolidated  (denser),  the  vibration  is  greater  and 
more  easily  distinguished, — the  vocal  fremitus  is  increased. 

In  feeble  persons,  or  when  any  cause  interferes  with  the  trans- 
mission of  the  vibrations,  the  vocal  fremitus  is  ditninished  or  absent. 


DISEASES  OF  THE   RESPIRATORY  SYSTEM.  247 


MENSURATION. 

Mensuration,  or  measurement  of  the  chest,  is  of  little  practical 
importance,  and  hence  seldom  performed.  The  only  measurement 
likely  to  be  required  is  the  circular  or  circumferential,  in  different 
parts  of  the  chest,  which  is  performed  with  either  an  ordinary  gradu- 
ated tape  measure  or  a  double  tape  measure,  made  by  uniting  two 
tapes  in  such  a  manner  that  they  start  in  opposite  directions  from  the 
same  point  at  the  mid-spinal  line.  The  tapes  drawn  around  each 
side  until  they  meet  at  the  id-sternal  line,  on  a  line  immediately 
above  the  nipple,  or  on  the  level  of  the  sixth  rib  near  its  attachment 
to  the  cartilage, — the  sixth  costo-sternal  joint, — the  patient  first  being 
directed  to  effect  a  complete  expiration,  the  number  of  inches  noted, 
and  then  to  take  a  deep  inspiration,  the  increase  in  inches  noted,  the 
difference  between  the  two  giving  a  rough  estimate  of  the  capacity 
of  the  lungs. 

In  right-handed  persons  the  right  side  is  usually  one-half  to  three- 
fourths  of  an  inch  larger  than  the  left;  if  larger  than  this,  it  is  usually 
the  result  of  some  abnormal  condition. 

In  well-developed  men  the  chest  measures  at  the  upper  part  about 
thirty-three  to  thirty-five  inches  during  expiration,  and  is  increased 
fully  three  inches  upon  inspiration. 


PERCUSSION. 

Percussion,  or  "  The  act  of  striking,"  to  ascertain  the  composition 
of  structures,  affords  signs  and  informationof  great  value  in  diagnosis. 

There  are  two  methods  employed,  immediate  and  mediate. 

Immediate,  or  direct  percussion,  is  performed  by  striking  the  thorax 
directly  with  the  points  of  the  fingers  or  the  palmar  surface  of  the 
hand.  This  method  of  percussion  has  been  generally  abandoned,  as 
it  does  not  enable  the  physician  to  distinguish,  with  sufficient  correct- 
ness, between  the  various  shades  of  difference  in  the  pitch  or  quality 
of  percussion  sounds. 

Mediate,  or  indirect  percussion,  may  be  practised  in  three  different 
ways,  to  wit : 

First. — ^With  the  finger  of  one  hand  interposed  between  the  body 
percussed  and  the  percussing  finger. 


248  PRACTICE    OF    MEDICINE. 

Second. — With  the  finger  acting  as  a  pleximeter  and  the  percussion 
hammer. 

Third. — With  the  percussion  hammer  and  the  pleximeter. 

The  first  of  these  modes  affords  the  most  correct  and  ready  infor- 
mation regarding  the  resistance  of  the  parts  percussed.  The  skillful 
use  of  the  fingers  is  more  difficult  to  acquire  than  that  of  the  plexi- 
meter and  hammer;  but  if  the  examiner  has  acquired  sufficient  skill 
in  its  performance,  an  absolutely  accurate  result  may  be  obtained. 
"  He  who  is  skilled  in  digital  percussion  will  be  able  to  percuss  equally 
well  with  the  hammer,  the  inverse  of  which  does  not  always  hold 
good."  In  addition  to  being  proficient  in  the  technical  7nodus  oper- 
andi, it  is  necessary  to  possess  a  sensitive  ear,  educated  to  distinguish 
between  the  various  shades  of  the  sounds. 

When  the  fingers  are  employed,  it  is  a  matter  of  choice  whether  one 
or  more  fingers  are  used  as  the  pleximeter.  Usually  the  last  phalanx 
of  the  first  or  second  fingers  of  the  left  hand  are  used,  the  other  fingers 
being  raised  from  the  chest,  so  as  not  to  interfere  luith  the  sound 
vibrations  ;  they  should  be  applied  yf/v;//}/  and  evetily  to  the  surface, 
thus  preventing  the  slipping  of  the  soft  parts,  and  also  to  determine 
the  resistance  of  the  chest  walls  when  the  blow  is  given.  The  rounded 
ends  of  the  first  and  second  fingers  of  the  right  hand  are  used  as  a 
hammer,  striking  the  pleximeter  fingers  in  such  a  manner  that  the 
nails  shall  not  touch  the  skin  of  the  underlying  fingers.  The  force 
employed  varies  in  different  regions,  but  usually,  for  the  chest,  should 
be  only  of  moderate  degree.  Forcible  percussion  is  of  use  only  when 
the  sound  of  deep-seated  organs  is  desired. 

The  stroke  should  be  made  perpendicularly  to  the  surface,  and  not 
slanting,  as  is  too  often  done.  The  whole  movement  should  proceed 
only  from  the  wrist-Joint,  and  ought  not  to  be  too  rapid  or  unequal, 
or  of  great  force,  the  fingers  being  rapidly  withdrawn,  so  as  not  to 
interfere  with  the  vibrations. 

The  objects  of  percussion  are  to  elicit  certain  sounds,  and  the 
amount  o{  resistance  or  elasticity  of  the  organs  percussed. 

The  main  sounds  elicited  by  percussion  are  the  dull,  clear,  and 
tytnpanitic.  Familiarity  with  the  intensify,  character,  and  pitch  of 
each  of  these  sounds  is  essential. 

When  percussing  the  healthy  chest,  the  sound  obtained  is  termed 
the  normal  pulmonary  resonance.  It  is  of  variable  intensity,  depend- 
ing upon  the  force  of  the  stroke  employed  and  the  amount  of  adipose 


DISEASES   OF   THE   RESPIRATORY   SYSTEM.  249 

and  muscular  tissues  covering  the  thorax,  and  the  tension  of  the  chest 
walls. 

There  is  no  exact  standard  of  the  normal  pulmonary  or  vesicular 
resonance,  but  if  the  two  sides  of  the  chest  are  compared,  the  normal 
standard  of  each  person  is  obtained. 

The  character  is  termed  pulmonary  or  clear,  as  characteristic  of 
the  healthy  chest  wall.     The  pitch  is  always  relatively  low. 

The  sounds  elicited  by  percussing  a  healthy  chest  are  not,  however, 
alike  over  all  its  parts. 

Anteriorly,  the  portion  of  lung  above  the  clavicle  yields  a  sound 
which  becomes  somewhat  tympanitic  as  the  trachea  is  approached. 

Over  the  clavicle  the  sound  is  clear  and  pulmonary  at  the  centre  of 
the  bone,  but  at  the  scapular  extremity  it  is  duller,  and  toward  the 
sternum  it  becomes  somewhat  tympanitic. 

At  the  infra- clavicular  region  the  resonance  is  clear  and  distinct, 
but  little  resistance  being  offered  to  the  percussing  finger,  and  the 
sound  elicited  may  be  taken  as  the  type  of  the  pulmonary  resonance. 
In  this  region,  however,  a  slight  disparity  exists  between  the  two  sides ; 
on  the  right  side  the  sound  is  less  clear,  shorter,  and  of  a  higher  pitch 
than  on  the  left  side. 

In  the  jnammary  region  of  the  right  side  the  resonance  of  the  lung 
is  not  so  clear,  the  sound  being  modified  by  the  size  of  the  mamma 
and  the  upper  border  of  the  liver.  On  the  left  side  the  heart  deadens 
the  sound  from  the  fourth  to  the  sixth  rib,  and,  in  a  transverse  direc- 
tion, from  the  sternum  to  the  left  nipple.  This  dull  sound  in  the  left 
mammary  region  is  lessened  in  extent  during  full  inspiration,  and  in 
emphysema,  when  the  lung  more  completely  covers  the  heart. 

In  the  infra-maminary  region  on  the  right  side  the  percussion  note 
is  dull,  except  during  the  act  of  complete  inspiration,  when  the  liver 
is  displaced  downward  by  the  inflated  lung.  In  the  left  infra-mam- 
viary  region  the  sound  consists  of  a  mixture  of  the  dull  sound  of  the 
heart  and  spleen  and  of  the  clear  sound  of  the  lung,  together  with 
the  tympanitic  sound  of  the  stomach. 

Over  the  upper  part  of  the  sternum — above  the  third  rib — the  sound 
is  slightly  tympanitic.  Below  the  third  rib,  over  the  sternum,  the 
sound  is  dull,  due  to  the  presence  of  the  heart  and  liver. 

The  position  exercises  some  influence  on  the  results  of  percussion. 
More  accurate  results  are  obtained  when  the  patient  is  standing  or 
sitting  than  when  recumbent.     While  the  front  of  the  chest  is  per- 


250  PRACTICE    OF    MF.niCINE. 

cussed,  the  arms  should  hang  loosely  by  the  sides;  the  hands  may 
be  clasped  across  the  top  of  the  head  during  tlie  percussion  of  the 
axillary  region  ;  during  the  examination  of  the  back  the  head  must 
be  bent  forward  and  the  arms  tightly  crossed  in  front. 

On  the  />os h'rt'or  surfa.ce  of  the  chest  the  sound  also  varies  accord- 
ing to  the  part  percussed. 

Over  the  scapuIcB  the  sound  is  duller  than  between  these  bones  or 
below  their  inferior  angles. 

Over  the  infra-scapular  region  a  clear  sound  is  obtained  as  far  as 
the  lower  border  of  the  tenth  rib  on  the  right  side,  where  the  dullness 
of  the  liver  begins.  On  the  left  side,  below  the  angle  of  the  scapula, 
the  percussion  sound  is  tympanitic  if  the  intestines  are  distended,  or 
it  may  be  slightly  dull  if  the  spleen  is  enlarged. 

In  the  axillary  region  the  sound  is  clear  and  distinct  on  each  side. 

In  the  infra-axillary  region  of  the  right  side  the  sound  is  duller, 
owing  to  the  presence  of  the  liver  ;  at  the  corresf>onding  situation  on 
the  left  side  the  sound  is  clear  or  iytnpanilic,  from  the  distention 
of  the  stomach,  and  at  the  ninth  or  tenth  rib  of  the  left  axillary 
region  dullness  and  the  sense  of  resistance  mark  the  location  of  the 
spleen. 

The  sounds  obtained  by  percussion  of  the  unhealthy  or  abnormal 
chest  are  as  follows  : 

First. — Hyper-resonance ,  or  an  increase  of  the  normal  pulmonary 
resonance,  is  due  to  the  relative  increase  in  the  proportion  of  air  to 
the  solid  tissues  of  the  lung,  provided  the  tension  of  the  chest  walls 
be  not  altered,  occurring  in  emphysema  of  the  lungs,  atrophy  of  the 
lungs,  or  consolidation  of  the  opposing  lung. 

Second. —  Dullness  or  an  absence  of  resonance,  due  to  the  relative 
increase  of  solid  tissues  in  proportion  to  the  amount  of  air,  as  seen  in 
the  different  stages  of  phthisis,  in  pneumonia,  pleural  effusion,  and 
hydrothorax. 

The  pitch  is  increased  or  heightened  in  proportion  to  the  diminu- 
tion of  the  amount  of  the  air  and  the  increase  of  the  solids. 

If  there  be  entire  want  of  resonance,  the  percussion  note  is  said  to 
be  flat ;  if  there  is  a  slight  decrease  in  the  resonance  of  the  part,  the 
note  is  said  to  be  itnpaired. 

The  sense  of  resistance  is  greater,  the  more  marked  the  consolida- 
tion of  the  lungs  and  the  greater  the  tension  of  the  chest  walls. 

Third. —  Tympanitic,  or  \\\e.  drum-like  percussion  note,  is  a  non- 


DISEASES   OF  THE   RESPIRATORY  SYSTEM,  251 

vesicular  sound  having  the  character  elicited  by  percussing  over  the 
normal  intestines  ;  wherever  heard  it  indicates  the  presence  of  air  in 
conditions  similar  to  that  of  the  intestines,  to  wit :  inclosed  in  walls 
which  are  yielding,  but  neither  tense  nor  very  thick. 

When  elicited  over  the  chest  it  may  be  due  to  the  transmitted 
sound  of  the  distended  stomach  or  colon.  It  is  obtained  over  the 
chest  in  pneumothorax,  in  moderate  pleural  effusions  above  the  level 
of  the  liquid,  over  the  seat  of  cavities  in  the  pulmonary  tissue,  and 
in  cedema  of  the  lungs. 

The  tympanitic  percussion  note  differs  from  the  normal  pulmonary 
resonance  in  being  more  ringing  in  character  and  of  a  higher  pitch. 

The  amphoric  or  metallic  sound  is  in  reality  a  concentrated  tym- 
panitic sound  of  high  pitch,  and  denotes  a  large  cavity  with  firm, 
but  yet  elastic,  walls. 

The  cracked-pot  or  cracked-7netal  sound  is  another  variety  of  the 
tympanitic  sound.  The  condition  most  frequently  producing  this 
sound  is  a  cavity  in  the  lung  tissue,  communicating  with  a  bronchial 
tube.  It  requires  for  its  development  a  strong,  quick  blow  of  the 
percussing  finger,  with  the  patient's  mouth  open. 

RESPIRATORY  PERCUSSION. 

The  percussion  sound  will  vary  greatly  with  the  respiratory  move- 
nients.  If  a  full  inspiration  be  taken  and  percussion  performed,  then 
a  full  expiration  taken  and  percussion  performed,  and  then  the  chest 
percussed  during  the  normal  respiration,  slight  changes  in  the  char- 
acter and  pitch  of  the  note  are  obtained,  which  otherwise  would 
escape  detection.  Prof.  Da  Costa  has  designated  this  method,  respi- 
ratory percussion. 

AUSCULTATORY  PERCUSSION. 

This  method  consists  in  listening,  with  a  stethoscope  applied  to  the 
thorax,  to  the  sounds  elicited  by  percussion.  "  It  is  a  serviceable 
means  of  determining  with  accuracy  the  boundaries  of  various 
organs,  as  those  of  the  lungs  or  heart,  or  of  the  liver  or  spleen,  and 
yields  particularly  exact  results  when  carried  out  with  the  double 
stethoscope." 


252  PRACTICE    OF    MEDICINE. 


AUSCULTATION. 

Auscultation,  or  listening  to  the  sounds  produced  within  the 
chest  during  the  act  of  respiration,  coughing,  or  speaking,  furnishes 
the  most  reliable  means  of  studying  the  condition  of  the  lungs  and 
heart,  and  is,  therefore,  the  most  valuable  method  of  discriminating 
between  the  various  conditions  which  may  affect  the  lungs  and  heart. 

Auscultation  is  either  iuimediate  or  vu-diafe. 

It  is  immediate  when  the  ear  is  applied  directly  to  the  chest,  which 
may  be  either  denuded  or  thinly  covered. 

It  is  jnediate  when  the  sounds  are  conducted  to  the  ear  by  means 
of  a  tubular  instrument,  termed  a  stethoscope. 

For  ordinary  purposes,  immediate  or  direct  auscultation  is  suffi- 
cient, but  when  it  is  desirable  to  analyze  circumscribed  sounds,  as  in 
diseases  of  the  heart,  or  where  the  patient  objects  to  this  method,  on 
the  score  of  delicacy,  or  the  auscultator  objects,  on  account  of  the 
uncleanliness  of  the  person  examined,  the  stethoscope  is  to  be  pre- 
ferred. Moreover,  there  are  certain  parts  of  the  chest  which  can 
only  be  explored  satisfactorily  by  the  aid  of  a  stethoscope,  which 
instrument  has  the  additional  advantage  of  intensifying  the  sound. 

In  auscultation,  the  following  rules,  formulated  by  Prof.  Da  Costa, 
should  be  observed : 

"  I.  Place  yourself  and  your  patient  in  a  position  which  is  the  least 
constrained  and  permits  of  the  most  accurate  application  of  the  ear 
or  stethoscope  to  the  surface.  Above  all,  avoid  stooping,  or  having 
the  head  too  low. 

"  2.  Let  the  chest  be  bare,  or,  what  is  better,  covered  only  with  a 
towel  or  thin  shirt. 

"  3.  If  a  stethoscope  be  employed,  apply  closely  to  the  surface,  but 
abstain  from  pressing  with  it.  This  may  be  obviated  by  steadying 
the  instrument,  immediately  above  its  expanded  extremity,  between 
the  thumb  and  the  index  finger. 

"4.  Examine  repeatedly  the  different  portions  of  the  chest,  and 
compare  them  with  one  another  while  the  patient  is  breathing 
quietly.  Making  him  cough  or  draw  a  full  breath  is,  at  times,  of 
service:  especially  the  former,  when  he  does  not  know  how  to 
breathe." 


DISEASES   OF  THE   RESPIRATORY   SYSTEM.  253 

SOUNDS  IN  HEALTH. 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy  per- 
son, a  sound  is  heard  with  both  the  act  of  inspiration  and  expiration. 
Its  intensify  is  variable,  its  pitch  high,  and  its  quality  tubular  (to  wit: 
a  current  of  air  passing  through  a  tube — the  larynx  or  trachea).  The 
duration  of  the  sound  during  inspiration  being  somewhat  longer  than 
during  expiration.     A  short  pause  follows  the  act  of  expiration. 

This  sound  is  termed  the  normal  laryngeal  respiration,  and  is 
identical  in  character,  duration,  and  pitch  with  an  important  morbid 
sound,  termed  bronchial  respiration. 

The  sound  heard  by  placing  the  ear  over  the  lung  tissue  is  differ- 
ent ;  it  is  produced  in  the  very  finest  bronchial  tubes  and  air  cells  by 
their  expansion  and  contraction,  and  is  termed  the  7iormal  vesicular 
murmur. 

The  inspiratory  portion  of  the  sound  is  of  variable  intensity,  its 
pitch  is  low,  its  quality  soft  and  breezy,  designated  vesicular ;  its 
duratioft  is  during  the  entire  act  of  inspiration. 

The  expiratory  portion  of  the  sound  is  not  always  perceptible  ;  it  is 
oi  feeble  intensity,  very  low  pitch,  its  character  soft  and  blowing,  and 
its  duration  much  less  than  the  act  of  inspiration. 

It  is  to  be  remembered,  however,  that  the  vesicular  murmur  will  be 
ibund  to  vary  in  the  different  regions  on  the  same  side,  and  in  corre- 
sponding regions  on  the  two  sides  of  the  chest.  These  variations 
within  the  range  of  health  are  especially  important,  and  should  be 
memorized. 

Infra-clavicular  Region. — The  vesicular  murmur  in  this  region  on 
either  side  is  much  more  distinct  than  over  any  other  part  of  the 
chest. 

On  the  left  side  the  inspiratory  sound  is  of  greater  intensity,  of 
lower  pitch,  and  more  distinctly  vesicular  in  quality  than  that  heard 
upon  the  right  side.  On  the  right  side  the  expiratory  sound  is  nearly 
or  quite  the  same  in  length  as  the  inspiratory  sound,  and  is  higher  in 
pitch  and  more,  tubtilar  in  quality  than  the  expiratory  sound  upon  the 
left  side. 

Supra-scapular  Region. — Owing  to  the  small  number  of  air  vesicles 
and  the  large  number  of  bronchial  tubes,  and  their  nearness  to  the 
surface,  the  respiratory  murmur  has  an  intense,  high-pitched,  tubular 
and  expiratory  quality. 


254  PRACTICE    OF    MEDICINE. 

Scapuhir  Re-gioti. — Compared  with  the  infra-clavicular  region,  the 
respiratory  murmur  heard  over  the  scapulae  on  either  side  is  more 
feeble,  and  the  vesicular  quality  less  marked. 

Interscapular  Rrgion. — The  murmur  in  this  region  differs  from  the 
normal  laryngeal  breathing  only  in  intensity  and  duration. 

Infra-scapular  Region. — The  murmur  in  this  region  very  closely 
resembles  that  heard  in  the  left  infra-clavicular  region. 

Mammary  and  Infra-mamtnary  Regions. — The  murmur  in  these 
regions  differs  from  that  heard  in  the  infra-clavicular  region,  in  being 
of  less  intensity. 

Axillary  and  Infra-axillary  Regions. — The  respiratory  sound  in 
the  axillary  regions  is  as  intense  as  in  any  portion  of  the  chest.  In 
the  infra-axillary  regions  the  intensity  is  less  and  the  pitch  lower, 

VOICE   IK    HEALTH. 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy  per- 
son, and  he  be  directed  to  count  "  twenty-one,  twenty-two,  twenty- 
three,"  in  a  uniform  tone  and  with  moderate  force,  there  is  perceived 
a  strong  resonance,  with  a  sensation  of  concussion  or  shock,  and  a 
sense  of  vibration,  thrill,  or  fremitus,  the  voice  seeming  to  be  concen- 
trated and  near  the  ear.  Often  the  articulated  words  are  distinctly 
transmitted  (laryngophony). 

The  sounds  thus  heard  are  termed  the  normal  laryngeal  resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  anteriorly,  on 
either  side  of  the  chest  of  a  healthy  person,  and  he  be  directed  to 
count  "twenty-one,  twenty-two,  twenty-three,"  in  a  uniform  tone, 
with  moderate  force,  a  confused  distant  hum  is  perceived  of  variable 
intensity,  accompanied  with  more  or  less  vibration,  thrill,  or  fremitus, 
most  distinct  in  adults,  but  notably  weaker  in  women  than  in  men. 

This  sound  is  termed  the  normal  vocal  resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  anteriorly,  of 
a  healthy  person,  and  he  be  directed  to  whisper,  in  a  uniform  man- 
ner, the  words  "  twenty-one,  twenty-two,  twenty-three,"  there  is  heard 
a  sound  corresponding  closely  in  character  to  the  sound  of  expiration 
over  the  same  region  during  the  act  of  forced  respiration  ;  or,  in  other 
words,  a  feeble,  low-pitched,  blowing  sound. 

This  sound  is  termed  the  normal  bronchial  whisper,  and  is  produced 
by  the  movement  of  the  air  in  the  bronchial  tubes  during  the  act  of 
respiration. 


DISEASES   OF  THE   RESPIRATORY  SYSTEM.  255 

SOUNDS   IN   DISEASE. 

The  vesicular  murmur  may  undergo,  in  disease,  changes  in  its  hi- 
tensiiy,  its  j-hythin,  and  in  its  character. 

The  intensity  of  the  respiratory  murmur  may  be  : 

I .  Exaggerated  or  increased. 

1.  Diminished  ox  feeble. 

3.  Absefit  or  suppressed. 

Exaggerated  respiration  differs  from  the  normal  vesicular 
respiration  only  in  an  increase  in  the  intensity  of  the  respiratory 
sounds.  When  general  over  one  lung,  it  will  usually  indicate  deficient 
action  of  other  parts.  In  this  manner  an  effusion  compressing  the 
lung,  one-sided  deposits,  obstruction  of  the  bronchial  tubes  by  secre- 
tion, or  inflammation  of  the  lung  structure,  'necessitate  a  supple- 
mentary respiration  in  a  healthy  portion  of  the  same  lung  or  the  lung 
upon  the  opposite  side.  From  its  resemblance  to  the  loud,  strong, 
quick  respiration  of  young  children,  it  has  been  l^xxv^zdi  puerile  res- 
piration. 

Exaggerated  respiration  is,  therefore,  to  be  regarded  as  indirect 
evidence  of  disease  in  some  portion  of  the  pulmonary  tissue. 

Diminished  respiration,  called  also  senile  respiration,  as  being 
characteristic  of  old  age,  is  characterized  by  diminished  intensity  and 
duration  of  the  sound.  In  the  large  majority  of  instances  the  inspi- 
ration suffers  the  greatest,  the  expiratory  sound  not  diminishing  in  the 
same  proportion.  In  asthma,  emphysema,  diseasesof  the  larynx  and 
bronchial  tubes,  pleuritic  pain,  rheumatism  or  paralysis  of  the  chest 
walls,  or  in  thickening  of  the  pleural  membrane,  we  observe  super- 
ficial or  diminished  respiration.  When  one  side  of  the  chest  is  par- 
tially filled  with  fluid,  we  may  hear  a  deep-seated  but  feeble  breath 
sound. 

Absent  or  suppressed  respiration  occurs  whenever  the  action 
of  the  lung  is  suspended  ;  this  may  be  from  external  pressure,  as  when 
the  lung  is  compressed  by  the  presence  of  fluid  or  air  in  the  pleural 
cavity,  or  when  complete  obstruction  of  the  bronchial  tubes  prevents 
the  air  from  either  entering  or  escaping  from  the  lungs. 

The  rhythm  of  the  respiratory  murmur  may  be  ; 

I.  Interrupted  or  jerky, 

1.   The  interval  between  inspiration  and  expiratiott  prolonged. 

3.  Expiration  prolonged. 


250  PRACTICE    OF    MKUICINE. 

In  health  the  inspiratory  and  expiratory  sounds  are  even  and  con- 
tinuous, with  a  short  interval  between  each  act ;  this  may  be  altered 
in  disease,  and  both  sounds,  especially  the  inspiratory,  have  an  inter- 
rupted or  jerky  character,  termed  "  cog-wheel  respiration." 

This  jerky  breathing'  is  noted  in  some  spasmodic  affections  of 
the  air  tubes,  in  hysteria,  the  earliest  stages  of  pleurisy,  pleurodynia, 
and  the  early  stages  of  pulmonary  phthisis.  It  is  most  frequently 
associated  with  phthisis,  due  probably  to  the  adhering  to  the  walls  of 
the  finer  bronchial  tubes  of  tough  mucus,  which  obstructs  the  free 
entrance  and  exit  of  the  air;  it  is  usually  most  notable  under  the 
clavicles. 

The  interval  between  inspiration  and  expiration  may 
be  prolonged,  instead  of  these  two  sounds  closely  succeeding  each 
other.  When  this  occurs  the  inspiratory  sound  may  be  shortened, 
or  the  expiratory  sound  may  be  delayed  in  its  commencement.  If 
the  inspiratory  sound  is  shortened,  it  is  the  result  of  consolidation 
of  the  lungs;  if  the  expiratory  sound  is  delayed,  it  is  the  result  of 
lessened  elasticity  of  the  lung  structure,  and  is  most  commonly  asso- 
ciated with  emphysema. 

Prolonged  expiration  denotes  that  the  air  is  obstructed  in  its 
exit  from  the  lungs.  It  may  be  the  result  of  diminished  elasticity, 
the  result  of  emphysema,  or  from  the  deposit  of  tubercles,  which 
impair  the  contractile  power  of  the  lungs.  If  the  former,  it  is  asso- 
ciated with  clearness  on  percussion;  if  the  latter,  however,  with 
impaired  resonance  on  percussion.  When  prolonged  expiration  is 
detected  at  the  apex  of  the  lung,  and  is  associated  with  impairment 
of  the  normal  pulmonary  resonance,  it  is  for  the  most  part  the  result 
of  a  tubercular  deposit. 

The  quality  of  the  respiratory  murmur  may  be  : 

1.  Harsh,  termed  vesiculo-brotichial respiration. 

2.  Bronchial. 

3.  Cavernous. 

4.  Amphoric. 

Harsh  respiration,  or,  as  it  is  termed  by  Prof.  Da  Costa,  vesiculo- 
(Jrtf«t//w/ respiration,  is  that  variety  in  which  both  the  inspiratory  and 
expiratory  sounds  have  lost  their  natural  softness.  It  generally  indi- 
cates more  or  less  consolidation  of  lung  tissue.  In  normal  vesicular 
respiration  the  sounds  produced  by  the  air  expanding  the  air  cells  and 
finer  bronchial  tubes  obscures  the  sound  produced  by  the  passage  of 


DISEASES   OF  THE   RESPIRATORY   SYSTEM.  257 

air  through  the  larger  bronchial  tubes,  the  healthy  lung  being  an 
imperfect  conductor  of  sound,  so  that  as  soon  as  any  portion  of  the 
lung  becomes  consolidated  the  vesicular  element  of  the  respiratory 
sound  is  diminished,  the  bronchial  element  becoming  prominent. 
Harsh  respiration  is,  then,  a  union  of  the  vesicular  and  bronchial 
sounds,  being  a  vesicular  sound  mixed  with  some  of  the  qualities  of 
a  bronchial  sound,  the  expiration  being  prolonged  and  tubular  in 
character.  It  is  present  when  the  bronchial  mucous  membrane  is 
swollen,  as  in  the  earlier  stages  of  bronchitis,  also  in  the  earlier  stages 
of  phthisis  and  pneumonia. 

Bronchial  respiration  is  characterized  by  an  entire  absence  of 
all  the  vesicular  quality.  Inspiration  is  of  high  pitch  and  tubular  in 
character;  expiration  still  higher  in  pitch,  of  greater  intensity, ^r<7- 
longed  and  tubular  in  quality  ;  the  two  sounds  being  separated  by  a 
brief  interval. 

The  bronchial  respiration  encountered  in  disease  closely  resembles 
that  heard  in  health  over  the  larynx  or  trachea.  Whenever  bronchial 
respiration  is  present  where,  in  health,  the  normal  vesicular  murmur 
should  be  heard,  it  indicates  consolidation  of  the  lung  structure. 

Cavernous  respiration  is  a  variety  of  the  bronchial  respiration, 
at  least  so  far  as  the  quality  of  the  sound  is  concerned.  It  is  essen- 
tially a  blowing  sound,  yet  not  always  heard  during  both  the  acts  of 
inspiration  and  expiration,  being  often  only  perceptible  in  the  one, 
and  in  the  other  mixed  with  gurgling  sounds.  Its  pitch  is  lower  than 
that  of  ordinary  bronchial  respiration,  and  its  character  \?>  hollow. 

For  its  production  there  must  be  a  cavity  of  considerable  size  in 
the  lung  substance,  not  filled  with  fluid,  near  the  surface  of  the  chest 
walls,  communicating  with  a  bronchial  tube.  It  is  met  with  most 
commonly  in  the  last  stages  of  pulmonary  consumption,  although 
hollow  spaces  of  any  kind,  from  abscess  or  dilatation  of  the  bronchial 
tubes,  occasion  it. 

Amphoric  respiration  is  a  blowing  respiration,  having  a  musi- 
cal or  metallic  quality.-  It  is  a  variety  of  bronchial  respiration  pro- 
duced in  a  large  cavity  with  firm  walls,  permitting  the  reflection  of 
the  sound.  An  imitation  of  this  sound,  though  only  an  imperfect 
one,  is  produced  by  blowing  over  the  mouth  of  an  empty  bottle. 
The  amphoric  character  is  present  with  both  the  acts  of  inspiration 
and  expiration. 

Amphoric  or  metallic  respiration  is  indicative  of  a  large  cavity,  not 

17 


258  PRACTICE    OF    MEDICINE. 

common  in  phthisis,  but  much  oftener  heard  at  the  upper  part  of  a 
lung  compressed  by  fluid  and  air,  as  in  pneumo-hydrothorax. 


RALES. 

Rales,  or,  as  they  are  termed,  adventitious  sounds,  because  they 
have  no  analogue  in  the  healthy  state,  cannot  be  considered  as  modi- 
fications of  the  normal  respiration. 

Grouped  according  to  the  anatomical  situation  in  which  they  are 
produced,  we  have : 

1 .  Laryngeal  and  tracheal  rales. 

2.  Bronchial  rales. 

3.  Vesicular  rales. 

4.  Cavernous  rales. 

5.  Pleural  rales. 

Rales  may  be  divided  into  two  groups,  according  to  their  character, 
to  wit:  dry  and  moist,  and  may  be  audible  either  during  the  act  of 
inspiration  or  expiration,  or  during  both. 

Dry  rales,  for  the  most  part,  are  produced  by  the  vibration  of 
thick  fluids  which  the  air  cannot  break  up,  and  which,  therefore, 
temporarily  lessens  the  calibre  of  the  bronchial  tubes.  When  this 
narrowing  exists  in  the  smaller  bronchial  tubes  the  resulting  sound  is 
high-pitched  or  the  rale  is  said  to  be  sibilant  or  whistling;  when  the 
narrowing  exists  in  the  larger  bronchial  tubes,  the  rale  \s  low-pitched, 
more  musical  in  character,  or  sonorous. 

Dry  rales  are  particularly  prone  to  be  dislodged  by  coughing,  and 
when  they  are  uninfluenced  by  the  acts  of  breathing  and  coughing, 
they  do  not  depend  upon  the  presence  of  secretions,  but  upon  the 
narrowing  of  the  air  tubes  from  the  pressure  of  tumors,  or  from  a 
thickened  fold  of  mucous  membrane,  or  from  a  spasmodic  contrac- 
tion of  the  air  tubes. 

Moist  rales  are  those  produced  by  the  air  passing  through  thin 
fluids,  such  as  mucus,  blood,  serum,  or  pus,  during  the  respiratory 
movements.  When  the  fluid  exists  in  the  smaller  bronchial  tubes, 
the  rales  are  termed  small  bubbling,  mucous,  or  subcrepitant.  When 
the  fluid  is  in  the  large  bronchial  tubes,  the  lales  are  said  to  be 
large  bubbling  or  mucous. 

Moist  rales  are  not  persistent,  but  vary  in  intensity,  and  shift  their 


DISEASES   OF  THE   RESPIRATORY   SYSTEM.  259 

position  as  the  air  drives  the  hquid  which  occasions  them  before  it, 
or  during  violent  attacks  of  coughing,  or  after  copious  expectoration. 

Laryngeal  and  tracheal  rales  are  those  produced  within  the 
larynx  and  trachea,  and  may  be  either  moist  or  dry.  The  moist  or 
bubbling  sounds,  produced  when  mucus  or  other  liquids  accumulate 
in  this  part  of  the  air  tubes,  frequently  occur  in  the  moribund  state, 
and  are  then  known  as  the  "  death  rattles."  When  not  due  to  this 
condition  they  denote  either  insensibility  to  the  presence  of  liquid, 
as  in  stupor  or  coma,  or  inability  to  remove  liquid  by  the  act  of  ex- 
pectoration, as  in  croup  or  inflammation  of  these  parts  in  the  very 
feeble. 

The  dry  rales  produced  within  the  larynx  or  trachea  are  generally 
caused  by  spasm  of  the  glottis — to  wit:  laryngismus  stridulus,  whoop- 
ing cough  or  croup,  or  from  the  presence  of  a  foreign  body  in  the 
part. 

Bronchial  rales,  resulting  from  the  passage  of  air  through  the 
thin  liquid,  occasion  bubbling  sounds.  When  the  liquid  is  present 
in  the  large-sized  bronchial  tubes,  the  rales  are  said  to  be  large 
bubbling,  or  large  mucous  rales,  occurring  in  acute  or  chronic 
bronchitis. 

When  the  liquid  is  in  the  smaller  bronchial  tubes,  the  resulting  rale 
is  called  small  bubbling,  small  mucous,  or  subcrepitant,  also  occurring 
in  acute  or  chronic  bronchitis. 

Bronchial  rales,  due  to  the  narrowing  of  the  tube  by  its  spasmodic 
contraction,  or  to  the  presence  of  tough,  tenacious  mucus,  which  is  put 
into  vibration  by  the  passage  of  the  air  through  the  bronchial  tubes,  are 
termed  dry  bronchial  rales.  Frequently  they  are  suggestive  of  cer- 
tain familiar  sounds,  such  as  snoring,  cooing,  humming,  or  wheezing, 
or  they  are  often  musical  tones.  When  produced  in  the  smaller 
bronchial  tubes,  they  are  termed  sibilant,  or  high-pitched  rales ; 
when  produced  in  the  larger  bronchial  tubes,  they  are  termed 
sonorotis  or  low-pitched  rales.  They  principally  occur  in  the  dry 
stage  of  bronchitis,  or  during  an  asthmatic  paroxysm. 

The  vesicular  rale,  or,  as  it  is  more  commonly  termed,  the 
crepitant  rale,  is  produced  within  the  air  vesicles  or  at  the  terminal 
portion  of  the  smaller  bronchial  tubes. 

It  is  to  be  distinguished  from  very  fine  bubbling  sounds,  or  the  sub- 
crepitant rale.  "  //  is  a'very  fine  sound,  or  rather  series  of  very  fine 
uniform  sounds,    occurring  in  puffs   and  limited   to    inspiration." 


260  PRACTICE   OF    MEDICINE. 

(Da  Costa.)  It  resembles  the  noise  occasioned  by  throwing  salt  on  the 
fire,  or  alternately  pressing  and  separating  the  tliumb  and  finger, 
moistened  with  a  solution  of  gum  arable,  and  held  near  the  ear,  or 
rubbing  together  a  lock  of  dry  hair  near  the  ear. 

The  crepitant  rale  is  produced  by  the  movement  of  fluid  in  the 
air  cells  or  in  the  finest  extremities  of  the  bronchial  tubes,  or  by  the 
forcing  open,  during  the  act  of  inspiration,  of  the  air  cells  aggluti- 
nated by  exuded  lymph.  These  sounds  may  be  defined  as  being 
very  fine,  dry,  crackling  sounds,  heard  at  the  end  of  inspiration. 
They  are  usually  present  in  the  first  stage  of  pneumonia,  but  when 
limited  to  the  apices  are  significant  of  the  incipient  stage  of  phthisis. 

Cavernous  rales,  or,  as  they  are  commonly  termed,  gurgling 
rales,  are  produced  in  a  pulmonary  cavity  of  considerable  size, 
containing  a  large  amount  of  liquid  communicating  freely  with  a 
bronchial  tube.  The  sound  is  occasioned  by  the  agitation  of  the 
liquid  within  the  cavity,  and  may  be  compared  to  the  sound  pro- 
duced by  the  boiling  of  liquid  in  a  flask  or  large  test-tube.  The  sound 
is  sometimes  high  pitched  or  musical,  whence  it  has  been  termed 
"amphoric  gurgling,"  but  it  is  generally  low  in  pitch.  The  rale  is 
heard  almost  exclusively  during  the  act  of  inspiration,  and  its  diag- 
nostic importance  relates  to  the  advanced  stage  of  phthisis. 

Pleural  rales  may  be  either  dry  or  moist. 

Dry  pleural  rales,  or,  as  they  are  more  commonly  \.^xvnt^,  friction 
sounds,  are  occasioned  when  the  surfaces  of  the  pleura  are  covered 
with  a  glutinous  substance  preventing  the  unobstructed  movements  of 
the  pleural  surfaces  upon  each  other  during  the  respiratory  acts,  for 
in  health  these  movements  occasion  no  sound  whatever.  The  sounds 
are  generally  interrupted  or  irregular,  occurring  during  the  act  of 
inspiration  or  expiration,  or  during  both  acts.  The  character  of  the 
sound  is  variable,  being  termed  rubbing,  grazing,  rasping,  grating,  or 
creaking,  according  to  the  intensity  of  the  respiratory  acts  and  the 
amount  of  exudation. 

They  are  distinguished  by  the  apparent  nearness  of  the  sound  to 
the  ear,  and  are  usually  intensified  by  firm  pressure  of  the  stetho- 
scope upon  the  chest.  When  the  chest  is  fixed,  especially  at  the 
lower  two-thirds,  and  the  ear  applied  over  the  seat  of  the  sound,  it 
will  be  found  to  have  disappeared.  The  sound  is  diagnostic  of  the 
first  stage  of  pleurisy  or  the  pre-adhesive  stage  of  tuberculosis  of  the 
pleura. 


DISEASES  OF  THE   RESPIRATORY   SYSTEM.  261 

Moist  friction  sounds  are  produced  in  the  same  manner  as  those 
just  mentioned,  the  exudation  being  softened  in  character.  This 
sound  is  frequently  confounded  with  moist  bronchial  rales,  and  its 
discrimination  is  often  only  positive  by  a  careful  study  of  the  symp- 
toms and  concomitant  signs  present. 

Metallic  tinkling  is  a  sign  of  pneumo-hydrothorax  with  per- 
foration of  the  lung,  and  when  found,  is  usually  diagnostic  of  this 
affection,  although  it  occurs  rarely  in  cases  of  phthisis  with  a  large 
cavity,  the  physical  conditions  for  its  production  being  similar  to  those 
in  pneumo-hydrothorax — to  wit :  a  space  of  considerable  size  contain- 
ing air  and  liquid,  the  space  communicating  with  the  bronchial  tubes. 

It  consists  of  a  series  of  tinkliftg  sounds,  of  high  pitch,  silvery  or 
metallic  in  tone,  and  is  very  well  imitated  by  dropping  a  small  marble 
into  a  metallic  vase.  It  occurs  irregularly,  not  being  present  with 
every  act  of  breathing,  and  may  be  produced  by  forced,  when  not 
heard  during  tranquil,  breathing. 

Were  it  not  for  the  location  and  the  absence  of  concomitant  signs, 
it  might  be  confounded  with  tinkling  sounds  sometimes  produced 
within  the  stomach  and  transverse  colon  ;  these  latter  sounds  must  be 
kept  in  mind  in  ausculting  the  lower  chest  area. 


THE  VOICE   IN  DISEASE. 

The  normal  vocal  resonance,  as  heard  over  the  third  rib  of 
the  chest  anteriorly  on  each  side,  may  have  its  intensity — 

1.  Diminished  or  absetii. 

2.  Iticr eased  or  exaggerated. 

Or  its  resonance  may  be  of  the  character  of — 

3.  Bronchophony. 

4.  Pectoriloquy. 

5.  yEgophony. 

6.  Amphoric  voice. 

The  vocal  resonance  may  be  diminished  or  feeble  in 
bronchitis  with  free  secretion,  pleurisy  with  effusion,  or  in  complete 
consolidation  of  the  lung  structure  and  the  bronchial  tubes. 

The  vocal  resonance  is  absent  in  pneumothorax  and  in 
pleurisy  with  effusion. 

Exaggerated  vocal  resonance  differs  from  the  normal  vocal 


262  PRACTICE    OF    MEDICINE. 

resonance  in  a  slight  increase  of  its  density.  It  denotes  a  slight 
degree  of  solidification  of  lung  tissue,  and  is  chiefly  of  value  in  the 
diagnosis  of  tubercle. 

Bronchophony,  or  the  voice  concentrated  near  the  ear,  raised 
in  pitch  and  in  intensity,  denotes  complete  consolidation  of  the  pul- 
monary tissue  in  those  parts  in  which  the  sound  is  abnormally 
present. 

Pectoriloquy  is  complete  transmission  of  the  voice  to  the  ear, 
the  articulated  words  being  distinctly  recognized.  It  has  a  close 
resemblance  to  the  resonance  heard  over  the  larynx  in  health.  Its 
presence  indicates  either  a  pulmonary  cavity  or  more  complete  con- 
solidation— in  other  words,  an  exaggerated  bronchophony. 

/^gnphony  is  a  modification  of  bronchophony,  consisting  in 
tremulousness  of  the  voice,  its  character  nasal  or  bleating,  somewhat 
suggestive  of  the  cry  of  a  goat.  When  heard  it  may  be  considered  a 
sign  of  pleurisy  with  slight  efTusion,  or  of  pleuro-pneumonia. 

Anaphoric  voice,  or  "the  echo,"  as  it  is  sometimes  called,  is  a 
musical  sound,  of  a  somewhat  hollow,  metallic  character,  like  that 
produced  by  blowing  into  an  empty  bottle.  It  is  sometimes  produced 
in  large  cavities  within  the  lung,  but  is  especially  incident  to  pneumo- 
thorax. 

Increased  bronchial  -whisper  is  a  sound  in  which  the  whis- 
pered words  are  abnormally  intense,  and  higher  in  pitch  than  the 
normal  bronchial  whisper.  It  has  the  same  significance  as  exagger- 
ated vocal  resonance. 


SUCCUSSION. 

The  Buccussion  or  splashing  sound  is  pathognomonic  of  one 
affection — namely,  pneumo-hydrothorax. 

It  is  obtained  by  jerking  the  body  of  a  patient  with  a  quick,  some- 
what forcible  movement,  the  ear  being  very  near  or  in  contact  with 
the  chest. 

The  sound  is  like  that  produced  when  a  small  keg,  partially  filled 
with  liquid,  is  shaken.  The  only  liability  to  error  is  in  confounding 
this  splashing  sound  with  that  sometimes  produced  within  the 
stomach  ;  but  attention  to  concomitant  signs  and  the  symptoms  will 
always  protect  against  this  error. 


DISEASES   OF  THE  NASAL   PASSAGES. 


263 


ASSOCIATION  OF  THE  PHYSICAL  SIGNS  (DA  COSTA). 
"  As  many  of  the  signs  elicited  by  the  various  methods  of  physical 
diagnosis   depend  on  the  same  physical  conditions,  they  may  be 
studied  in  groups.     The  following  will  be  usually  found  to  be  asso- 
ciated: 


Auscultation 


Percussion. 

OF 

Respiration. 

Auscultation 
OF  Voice. 

Vocal 

Fremitus. 

Clear,  .... 

Vesicular 

Normal  vocal 

Unimpaired. 

murmur  or 
its   modifi- 

resonance. 

cation. 

■  Bronchial, 
or  harsh 

Bronchophony. 

Increased. 

Dull,    .... 

respiration. 

Absent  respi- 
.     ration. 

Absent  voice. 

Diminished 
or  absent. 

Tympanitic,  . 

Cavernous  or 
feeble,    ac- 
cording  to 
cause. 

Uncertain  ; 
cavernous  or 
diminished. 

Uncertain  ; 
mostly  di- 
minished. 

Amphoric  or 
metallic. 

Amphoric  or 
metallic. 

Amphoric  or 
metallic. 

Mostly   di- 
minished. 

Cracked 
metal  sound. 

Cavernous 
respiration. 

Cavernous 
respiration. 

Uncertain. 

Physical  Conditions. 


Lung  tissue  healthy  or 
nearly  so  ;  at  any  rate, 
no  increased  density 
from  deposits,  etc. 

Solidification  of  pulmon- 
ary structure. 


Effusion  into  pleural  sac. 

Increased  quantity  of  air 
within  the  chest,  due  to 
a  cavity  or  to  overdis- 
tention  of  the  air  cells. 

Large  cavity  with  elastic 
walls. 

Generally  a  cavity  com- 
municating with  a  bron- 
chial tube. 


DISEASES  OF  THE  NASAL  PASSAGES. 


ACUTE  NASAL  CATARRH. 

Synonyms.  Acute  rhinitis;  acute  coryza;  "cold  in  the  head." 
Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  (pituitary  or  Schneiderian  membrane)  lining  the  nose  and 
the  cavities  communicating  with  it ;  characterized  by  feverishness, 
feeling  of  fullness  and  discomfort  in  the  head,  and  attended  with  dis- 
charges of  fluid,  watery,  mucous,  or  muco-purulent  in  character. 

Pathological  Anatomy.  Hyperemia  of  the  mucous  mem- 
brane, attended  with  redness,  swelling,  and  deficient  secretion.  This 
tumefaction  is  partly  increased  by  an  csdematous  infiltration,  causing 
a  quantity  of  colorless,  salty,  and  very  thin  liquid  to  flow  from  the 


264  PRACTICE    OF    MEDICINE, 

nose.  The  secretion  soon  assumes  the  character  of  thick,  tenacious 
mucus  or  muco-pus,  due  to  the  desquamation  of  the  epithelium  of  the 
nasal  mucous  membrane,  and  a  copious  generation  of  young  cells, 
the  hyperasmia  and  the  swelling  of  the  membrane  diminishing. 

The  respiratory  portions  of  the  nasal  fossae  are  more  markedly 
affected  than  are  the  olfactory. 

Rarely,  and  then  in  new-born  infants  and  those  affected  with  the 
eruptive  fevers,  the  exudation  in  the  nasal  passages  is  of  a  fibrinous 
nature,  somewhat  similar  to  that  observed  in  diphtheria. 

Causes.  Atmospherical  changes  are  the  most  frequent  and  in- 
fluential. Exposure  of  the  neck  to  a  draught  of  cold  air,  or  of  the 
feet  and  ankles  to  cold  and  dampness,  or  changing  from  a  warm  to  a 
cold  atmosphere  suddenly,  are  among  the  most  usual  causes.  Irri- 
tating gases  and  vapors,  dust,  certain  powders,  as  ipecac  and  tobacco. 
The  scrofulous  taint  and  the  rheumatic  diathesis  seem  to  render  the 
mucous  membrane  susceptible  to  frequent  attacks. 

Acute  coryza  is  usually  present  in  the  initial  stage  of  measles  and 
influenza;  nearly  always  present  in  facial  erysipelas. 

Epidemic  influence  occasionally  prevails  on  an  extensive  scale. 
The  poison  of  syphilis  or  the  use  of  the  iodide  of  potassium  not  in- 
frequently act  as  exciting  causes. 

At  times  the  catarrh  seems  to  spread  by  contagion. 

Symptoms.  "A  cold  in  the  head"  is  usually  preceded  by  a 
feeling  of /(Z^^/Vz/rt'i?  or  weariness  and  more  or  less  frontal /wat/ac/ie ; 
then  occur  irregular  chilly  sensatio7is  in  the  back,  followed  by  more  or 
less  feverishness  and  an  uncomfortable  feeling  of  dryness  in  the  nares, 
with  a  strong  inclination  to  siiceze.  This  is  soon  followed  by  an 
abundant  luatery  and  saline  discharge,  which  is  continually  dripping 
from  the  nostrils,  or  occasions  an  attack  of  sneezing  followed  by 
blowing  the  nose,  which  relieves  the  congested  and  swollen  mem- 
brane for  a  few  moments.  The  relief  is  temporary,  however,  the 
fullness  of  the  head  and  difficult  obstructed  nasal  respiration  rapidly 
returning.  The  anterior  nares  are  red  and  injianied,  and  the  eyes 
red  and  suffused  with  tears,  through  partial  or  entire  closure  of  the 
tear  ducts.  The  discharge  soon  assumes  a  purulent  character.  The 
voice  has  a  peculiar  tone,  rather  nasal  and  muffled  in  character. 
Within  a  few  days  the  swelling  subsides  and  secretion  lessens, 
health  being  restored  in  about  ten  days  from  'he  beginning  of  the 
attack. 


DISEASES   OF  THE   NASAL   PASSAGES.  205 

When  the  attack  has  almost  terminated,  hard  crusts  may  form 
within  the  nostrils,  either  on  the  septum  or  turbinated  bones,  which 
are  with  difficulty  expelled  by  blowing  the  nose. 

Complications.  Irritation  and  swelling  of  the  upper  lip,  from 
repeated  blowing  of  the  nose  and  the  constant  contact  of  the  irri- 
tating discharge. 

Extension  of  the  catarrh  to  the  ethmoid  or  sphenoid  cavities  or 
fro7ital  sinus,  causing  increased  and  severe  frontal  headache;  or  to 
the  antrum  of  Highmore,  causing  tenderness  over  one  or  both 
cheeks. 

Extension  to  the  Eustachian  tube  and  middle  ear,  causing  impaired 
hearing  ;  or  i\\&  pharytix  or  larynx,  causing  cough. 

Duration.  In  mild  cases  about  one  week ;  severe  cases  continue, 
more  or  less  marked,  for  two  weeks. 

Prognosis.  Favorable  if  early  and  proper  treatment  be  insti- 
tuted; if  neglected,  the  catarrh  tends  to  become  chronic.  In  very 
young  infants,  if  the  catarrh  is  not  rapidly  relieved,  loss  of  flesh  and 
strength  occur,  from  inability  to  nurse. 

Treatment.  Attacks  the  result  of  atmospherical  causes  may  be 
aborted  by  the  early  administration  of  qiiinincE  sulphas,  gr.  x-xv  (0.6-1 
Gm.),  with  morphin<z  sulphas,  gr.  ^  (0.016  Gm.),  or  the  early  use  of 
pulvis  ipecacuanh(B  et  opii,  gr.  v  (0.3  Gm.),  repeated  in  two  hours. 
Buckley  says  an  acute  cold  can  be  aborted  by  using  sodii  bicar- 
bonatis,  gr.  xx  (1.3  Gm.)  in  f^ij  (60  Cc.)  of  a  hot  fluid  every  half  hour 
for  three  doses  and  the  fourth  dose  in  one  hour. 

The  following  errhine  used  at  the  very  onset  has  proved  successful 
in  aborting  many  attacks  : 

R .     Alumenis, 

Bismuthi  subcarb., 

Pulv.  camphoree, aa  gr.  xx  aa  I.3    Gm. 

Morpliinffihydrochlor. , gr-  ij  -IS  Gm.  M. 

Et.  chart.  No.  xx. 

SiG. — Insufflate  one  powder  in  each  nostril  after  clearing  the  nose. 

If  the  attack  has  already  developed,  relief  is  soon  afforded  by 
tinctura  belladotincp,  Tt\^ij  (o  12  Cc),  every  hour  until  six  doses  are 
taken,  after  which  one  drop  every  two  or  three  hours  until  the  physi- 
ological actions  of  the  drug  are  produced ;  if  much  fever  be  present, 
tinctura  aconiti,  iTLj-ij  (0.06-0.12  Cc),  may  be  added;  the  addition 
of  catnphora  is  of  value  :  in  fact,  camphora  in  full  doses  at  the  onset 


266  PRACTICE    OF    MEDICINE. 

and  locally  will  often  abort  an  acute  catarrh.     The  following  combi- 
nation of  Dr.  Sajous  is  often  successful : 

HL .      Ammonii  cblor. , ►)  ij  2.6  Gm. 

Tinct.opii, Ttlxxx  2.     Cc. 

S.icch.  alb., 2J  4-     ^'"• 

Aq.  camphore, .    .  f^j  30.     Cc.  M. 

SiG. — One  teaspoonful  in  water  ever)'  hour  or  two. 

Attacks  of  acute  rhinitis  unaccompanied  by  febrile  reaction  are 
generally  promptly  aborted  by  a  four  per  cent,  solution  of  cocaina 
hydrochloras,  dropped  in  the  nostrils,  repeated  every  half  hour: 

With  either  of  the  above  plans  may  be  added  one  of  the  following 
errhines  : 

R.     Bismuth,  subnit., ^vj  24.       Gm. 

Pulv.  acacii^, 3  ij  8.       Gm. 

Morphincehydrochlor., g""-  'j  .13  Gm. 

SiG. — Every  hour  or  two.     (Ferrier. ) 

Or— 

li.     Pulv.  cubeba;, 3J  4.       Gm. 

Bismuth,  subnit., 3  ij  8.       Gm. 

Morphince  hydrochlor.,      .    .    .    .    gr.  ij  .13  Gm.  M. 

SiG. — Used  by  insiijiation  every  two  or  three  hours. 

Acute  coryza  occurring  in  infants  at  the  breast  is  controlled  by 
either  one  of  the  following  errhines,  thrown  into  the  nose  with  a 
powder  blower :  finely  powdered  saccharum  purificatum  (white),  or 
equal  parts  of  finely  powdered  saccharum  pitrificahon  dindcamphora, 
or  Robinson's  errhine  of  sacchartim  purificatum  and  campJiora,  each 
half  ounce  (15  Gm.)  finely  powdered,  and  acidtim  tannicum,  gr.  xl 
(2.6  Gm.). 

Attacks  of  nasal  catarrh  due  to  the  poison  of  syphilis  should  at 
once  be  placed  upon  the  proper  constitutional  treatment. 

Attacks  of  nasal  catarrh  associated  with  the  eruptive  or  mild  fevers 
require  no  special  treatment. 

It  is  well  to  remember  that  attacks  of  nasal  catarrh  occurring  in 
very  young  children  are  generally  the  result  of  hereditary  syphilis, 
and  should  be  treated  accordingly. 


DISEASES   OF  THE   NASAL   PASSAGES.  267 


CHRONIC  NASAL  CATARRH. 

Synonyms.     Chronic  rhinitis  ;  chronic  coryza. 

Definition.  A  chronic  inflammation  of  the  mucous  membrane 
lining  the  nasal  passages,  with  more  or  less  alteration  of  structure ; 
characterized  by  a  sensation  of  fullness  in  the  nares,  increased  secre- 
tion, and  a  perversion  of  the  special  sense  of  smell  and  of  hearing. 

Causes.  The  result  of  repeated  attacks  of  the  acute  variety ; 
inhalation  of  irritating  vapors  and  dust;  syphilis  and  scrofula. 

Pathological  Anatomy.  The  mucous  membrane  of  the  nares 
is  thickened,  of  a  dark-red,  sometimes  grayish  color,  the  superficial 
veins  dilated  and  varicose,  often  forming  polypoid  enlargements.  In 
many  cases  there  is  ulceration  of  the  structure,  with  more  or  less  loss 
of  substance ;  the  secretion  is  thick,  tough,  of  a  greenish  character, 
and  often  very  foetid  ;  large  collections  of  dried  mucus  are  often 
formed  upon  the  turbinated  bones  and  septum. 

Symptoms.  A  feeling  oi  fullness  in  the  nares,  ittcrease  of  the 
secretion,  the  character  being  thick  and  greenish,  which,  dropping 
posteriorly  into  the  pharynx,  causes  paroxysms  of  "hawking," 
which  are  more  marked  in  the  morning  immediately  after  rising. 

The  special  sense  of  smell  \?,  more  or  less  impaired,  and  in  many  in- 
stances entirely  abolished ;  the  special  sense  of  hearing  is  more  or  less 
diminished,  from  an  extension  of  the  inflammation  to  the  Eustachian 
tubes  ;  the  voice  has  a  peculiar  nasal  intonation. 

An  almost  constant  dnW  frontal  headache,  associated  with  a  feeling 
of  weight,  showing  the  extension  of  the  disease  to  the  infundibulum 
and  frontal  sinus. 

Sudden  changes  of  temperature  cause  acute  exacerbation  of  these 
symptoms,  when  there  is  superadded  difficult  nasal  respiration. 

If  tdceration  of  the  nares  occur,  the  discharge  has  a  fcetid  odor. 
This  condition  is  termed  ozcena. 

From  extension  of  the  inflammation  to  the  nasal  duct  or  its  ob- 
struction, the  tears  flow  over  the  malar  eminence  {epiphora),  leading 
to  more  or  less  congestion  of  the  eyes. 

Diagnosis.  Hypertrophy  of  the  turbinated  bones  and  naso- 
pharyngeal catarrh  are  constantly  misnamed  chronic  nasal  catarrh. 
The  rhinoscope  readily  determines  the  diagnosis. 

Prognosis.     Permanent  cure   is   seldom  obtained ;   the  disease 


2t')8  PRACTICE   OF    MEDICINE. 

being  so  decidedly  chronic  and  obstinate,  the  treatment  is  of  neces- 
sity protracted,  and  the  majority  of  patients  tire  of  it  before  a  com- 
plete cure  is  effected. 

Treatment.  If  it  depends  upon  diathetic  conditions,  the  cause 
must  be  ascertained  and  treatment  directed  accordingly. 

When  no  diathetic  cause  can  be  determined,  attention  should  be 
paid  to  the  general  health,  the  secretions  constantly  attended  to,  and 
ihe  diet  be  nutritious  and  digestible. 

Cleanliness  of  the  nasal  passages  is  of  the  utmost  importance,  and 
is  best  effected  by  the  post-nasal  syringe,  with  either  simple  or  medi- 
cated tepid  waters,  or  a  cleansing  solution,  such  as  Dobell's — to  wit: 

JBt.     Acidi  carbolic!, gr.  j  .065  Gm. 

Sodii  bicarbonat., 

Sodii  borat., aa     gr.  v  aa      .3      Gm. 

Glycerin!, fj^j  4.         Co. 

Aqua;,      f^j  30.         Co. 

SiG. — As  a  spray  or  witli  a  proper  syringe. 

Or  the  following  combination  of  Dr.  Sajous: 

U .      Sod!!  bicarb., 

Sodii  bibor., ^3.  gr.  v!ij         aa      .52  Gm. 

Ext.  pinus  canad.  fld. TTL  xv  i.      Cc. 

Glycenni, f  5  !j  8.      Cc. 

Aquce, adf^iv  ad  120.       Cc.  M. 

SiG. — Apply  with  atomizer  three  or  four  times  daily. 

After  which  decided  benefit  follows  the  use  of  one  of  the  following: 

li .     Acid!  borici, gr.  xxx  2.         Gm. 

Bismuth,  siibnit., ^ij  8.         Gm. 

Morphinie  hydrochlor.,      ....  gr.  j  .065  Gm.         M. 
Or— 

R.     Pulv.  sanguinarire 3J  4.    Gm. 

Acid,  tannic!, gr.  v  .3  Gm. 

Pulv.  camphorre, ^j  4.     Gm. 

Bismuth,  subnit., 3!]  8.     Gm.  M. 

SiG. — To  be  used  by  insufflation  or  as  a  snuff  every  three  or  four  hours. 

Or— 

R.     Ammonii  chloridi, 7^]  4.  Gm. 

Glycerin! fzij  8.  Cc. 

Ext.  pinus  canad.  fld., f  s  j  30.  Cc. 

Aqune  destil., adf^ij  ad   60.  Cc. 

SiG. — Five  or  ten  drops,  dropped  into  each  nostril  two  or  three  times  a  day, 
or  applied  with  a  camel's-hair  brush. 


DISEASES   OF   THE   PHARYNX.  269 

Or  the  following  pleasant  mixture  may  be  applied  to  each  nostril  ; 

R.     Tinct.  benzoin., ^S^^  ^5-     Cc. 

Tinct.  guaiaci, f^j  4.     Cc. 

Chloroform!, TT\^x  .6  Cc. 

Tinct.  myrrh.,     ...        ....  i^ss  2.     Cc. 

01.  amygd., n\y  .3  Cc.  M. 

SiG. — A  few  drops  in  each  nostril  once,  or  oftener,  a  day. 


DISEASES   OF   THE   PHARYNX. 


ACUTE  CATARRHAL  PHARYNGITIS. 

Synonyms.  Catarrhal  tonsillitis ;  angina  catarrhalis ;  acute 
"sore  throat." 

Definition.  An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  tonsils,  uvula,  soft  palate,  and  pharynx  ;  character- 
ized by  rigors,  fever,  painful  deglutition,  coughing,  or  constant  desire 
to  clear  the  throat,  with  a  more  or  less  decided  nasal  intonation  of 
the  voice. 

Causes.  Exposure  to  cold  and  damp ;  swallowing  hot  fluids  or 
food;  during  the  prevalence  of  scarlatina,  measles,  erysipelas,  influ- 
enza, diphtheria,  or  variola.  It  is  attributed  to  some  form  of  bacteria 
by  numerous  observers. 

Pathological  Anatomy.  The  mucous  membrane  and  sub- 
mucous tissues  of  the  uvula,  soft  palate,  fauces,  tonsils,  and  pharynx 
are  congested,  red,  and  swollen  ;  the  secretion  is  at  first  lessened  or 
eniirely  arrested,  later  it  is  increased,  but  of  a  thick,  tenacious,  opaque 
character.  The  swelling  is  most  evident  at  the  uvula,  due  to  the 
amount  of  relaxed  submucous  tissue,  which  is  especially  thick  and 
long,  often  resting  on  the  root  of  the  tongue  ("the  palate  is  down  "). 
Frequently  one  or  both  tonsils  are  swollen  to  such  an  extent  that 
the  fauces  are  completely  occluded,  and  the  condition  is  mistaken  for 
the  graver  phlegmonous  tonsillitis. 

In  severe  attacks  of  catarrhal  angina,  white  or  grayish-white  mem- 
branous masses  form  in  small,  irregular,  roundish  spots  on  the  red- 


270  PRACTICE    OF    MEDICINE. 

dened  mucous  membrane  of  the  tonsils,  soft  palate,  and  pharynx, 
causinj:^  the  affection  to  be  frequently  mistaken  for  diphtheria. 

Symptoms.  The  onset  is  usually  sudden,  with  rit^ors,  fever, 
thirst,  headache,  loss  of  appetite,  coated  tongue,  bad  taste,  foul 
breath,  dryness  in  the  throat,  painful  deglutition,  and  constant  desire 
to  clear  the  throat,  due  to  the  increased  length  of  the  uvula ;  as  the 
inflammation  proceeds  the  secretions  are  increased,  the  fluid  often 
filling  the  mouth,  causing  a  constant  desire  to  swallow,  each  act  being 
associated  with  acute  pain.  Not  infrequently  earache  adds  to  the 
patient's  distress,  from  extension  of  the  "  catarrh  "  to  the  Eustachian 
tubes  and  tympanum. 

In  severe  attacks  of  catarrhal  pharyngitis,  cases  which,  from  the 
intense  hyperemia,  have  been  termed  erysipelatous  or  erythematous 
pharyngitis,  the  muscles  of  the  palate  are  infiltrated  with  serum, 
which  greatly  interferes  with  their  function.  Under  normal  conditions 
the  contraction  of  the  muscles  of  the  anterior  half  arches  of  the  palate 
prevents  the  return  of  food  and  drink  into  the  mouth  ;  while  the  con- 
traction of  the  muscles  of  the  posterior  half  arches,  together  with  the 
uvula,  closes  the  passage  to  the  nose;  if  the  function  of  these  muscles 
be  impaired,  fluids  would  be  driven  through  the  nose  or  back  into  the 
'mouth  by  the  contractions  of  the  pharynx  in  the  act  of  deglutition.    . 

In  all  affections  of  the  pharynx  a  nasal  tone  is  pathognomonic, 
especially  if  the  muscles  of  the  half  arches  are  interfered  with. 

Varieties.  Exanthematous  pharyiigitis  is  the  form  of  the  affec- 
tion complicating  the  acute  infectious  diseases,  such  as  scarlatina, 
measles,  influenza,  and  small-pox. 

Erysipelatous  pharyngitis  is  the  form  complicating  facial  erysipelas ; 
rarely,  however,  the  affection  begins  in  the  pharynx,  spreading  to  the 
face  and  other  parts.  The  association  of  nasal  inflammation  with 
erysipelas  should  not  be  forgotten. 

Gangrenous  pharyngitis  may  occur  with  diphtheria,  scarlatina, 
erysipelas,  small-pox,  and  typhoid  fever.  The  symptoms  assume  a 
typhoid  (depressed)  character,  the  termination  being  usually  fatal. 

Phlegmonous  pharyngitis  is  the  variety  associated  with  an  accu- 
mulation of  pus  in  the  submucous  and  deeper  tissues  of  the  pharynx, 
constituting  a  retro  pharyngeal  abscess.  This  variety  of  pharyn- 
gitis may  follow  the  penetration  of  a  sharp  piece  of  bone  or  be  sec- 
ondary to  caries  of  the  cervical  vertebrae. 

Fibrinous  pharyngitis,  or,  as  it  is  sometimes  termed,  pseudo-mem- 


DISEASES   OF  THE   PHARYNX.  271 

branous,  is  considered  with  croup  and  diphtheria,  of  which  it  is  a 
variety. 

Diagnosis.  On  account  of  the  great  swelUng  of  the  tonsils,  it 
may  be  mistaken  for  acute  tonsillitis ;  but  the  mild  inflammatory 
symptoms  should  prevent  the  error. 

Cases  with  membranous  deposits  upon  the  tonsils,  soft  palate,  and 
pharynx,  are  no  doubt  often  misnamed  diphtheria  :  the  marked  differ- 
ence in  the  constitutional  symptoms  and  the  absence  of  the  Klebs- 
Loeffler  bacillus  should  prevent  the  error. 

Prognosis.  Favorable,  the  affection  terminating  in  three  or  four 
days  by  the  discharge  of  a  quantity  of  thick,  opaque  mucus. 

Treatment.  If  the  attack  is  the  result  of  exposure  to  cold  or 
damp,  or  a  symptom  of  some  one  of  the  infectious  diseases,  the  very 
best  results  follow  the  application  of  sodii  bicarbonas  by  insufflation. 
Opium  in  some  form,  alone  or  combined  with  ipecac  or  camphora, 
will  often  abort  an  attack  of  catarrh.  Salol,  gr.  iij  (0.2  Gm.),  and/-^<f«- 
aceiin,  gr.  iij  (0.2  Gm.)  combined  w'lih ptilv.  camphorcB,  gr.  j  (0.065  Gm.) 
(reducing  size  of  dose  for  children,),  repeated  four  to  six  times  daily, 
are  most  valuable  remedies  for  relieving  the  pain  in  all  varieties  of 
acute  anginas.  Sodii  salicylas,  gr.  x-xv  (0.6-1  Gm.)  hourly  until 
five  or  six  doses  are  taken,  often  acts  like  a  specific.  If  the  fever  be 
marked,  advantage  follows  the  addition  of  small  doses  of  tinctura 
acofiiti.  In  children  no  one  drug  can  compare  with  small  repeated 
doses  of  tinctura  aconiti.  Excellent  results  often  follow  the  use  of 
nuclein  (Aulde),  gr.  j-iij  (0.065-0.2  Gm.),  or  Trij-v  (0.065-0.3  Cc.) 
every  hour  or  two. 

Locally,  cocaine  painted  over  the  inflamed  parts,  of  the  strength  of 
a  four  per  centum  solution,  or  used  in  the  form  of  lozenges,  is  a  val- 
uable remedy.  Holding  small  pellets  of  ice  in  the  mouth  is  useful, 
or  the  application  of  either  heat  or  cold  to  the  angles  of  the  jaws. 
Gargles  ox  sprays  of  alujninis  [gr.  viij  (0.52  Gm.)  ;  aqus,  f3J  (30  Cc.)]  ; 
ammo7iii  chloridiim  [gr.  xx  (1.3  Gm.) ;  aquEe  f^j  (4  Cc.)]  ;  or  potassii 
chloras  [gr.  x  (0.6  Gm.) ;  aquse  f^j  (30  Cc.)],  used  at  frequent  inter- 
vals, often  allay  the  congestion  and  consequent  swelling.  For  the 
gangrenous  variety  stimulants  and  the  local  use  of  argenti  nitras. 

If  a  retro-pharyngeal  abscess  develop,  evacuate  the  pus  early  and 
give  quinines  sulphas  and  ferrwn  for  the  constitutional  symptoms 
which  may  develop. 


272  PRACTICK    OF    MKDICI.NH. 


ACUTE  TONSILLITIS. 

Synonyms.     Amygdalitis;  quinsy;  phlegmonous  pharyngitis. 

Definition.  An  acute  parenchymatous  inflammation  of  one  or 
both  tonsils,  with  a  strong  tendency  toward  suppuration;  character- 
ized by  moderate  fever,  pain  in  the  throat,  a  constant  desire  to  relieve 
the  throat,  painful  and  difficult  deglutition,  impeded  respiration,  and 
more  or  less  muffling  of  the  voice. 

Causes.  Generally  attributed  to  exposure  to  cold,  but,  in  the 
majority  of  instances,  the  exposure  is  so  slight  that  there  must  be  a 
predisposition  to  the  aflfection,  for  persons  once  affected  are  particularly 
prone  to  repeated  attacks  upon  the  slightest  exposure. 

Pathological  Anatomy.  One  or  both  tonsils  will  be  seen,  on 
inspection,  to  project  from  its  bed,  as  a  rounded,  deep  red  body, 
which  may  even  extend  beyond  the  median  line,  when  they  may  en- 
tirely occlude  the  isthmus  of  the  fauces;  the  half  arches  and  posterior 
border  of  the  soft  palate  are  reddened  and  somewhat  swollen.  The 
surface  of  the  tonsils  is  often  covered  with  small,  yellowish  points, 
which  closely  resemble  patches  of  false  membrane,  but  careful  in- 
spection will  show  that  they  are  beneath  the  mucous  membrane, 
being  only  the  distended  follicles  of  the  gland.  The  mucous  mem- 
brane of  the  fauces  and  pharynx  is  more  or  less  red  and  swollen. 

Symptoms.  Onset  more  or  less  sudden,  with  rigors,  rise  in  tem- 
perature, 102°  to  104°  Y .;  full,  frequent  pulse,  100  to  120;  headache, 
thirst,  pain  and  swelling  at  the  angle  of  the  jaw  with  a  constant 
desire  to  clear  the  throat ;  difficult  and  painful  deglutition,  from  the 
enlarged  tonsils  almost  closing  the  fauces,  when  the  respiration  is 
more  or  less  impeded ;  the  voice  is  more  or  less  muffled,  and  attempts 
at  phonation  increase  the  pain. 

Darting  pains  along  the  Eustachian  tubes  are  of  frequent  occur- 
rence, the  patient  complaining  of  earache  and  more  or  less  deafness. 

If  suppuration  be  imminent,  the  throat  becomes  more  painful,  the 
character  of  the  pain  throbbing,  the  febrile  phenomena  increase,  with 
more  or  less  depression,  the  symptoms  seeming  to  be  of  great  danger, 
when  suddenly,  after  an  effort  at  vomiting,  or  spontaneously,  the  ton- 
sillar abscess  bursts,  a  quantity  of  pus  escapes  from  the  mouth,  and 
prompt  relief  follows. 

Duration.    The  disease  lasts  from  three  to  seven  days,  terminat- 


DISEASES   OF   THE    PHARYNX.  273 

ing  either  by  suppuration  or  the  gradual  resolution  of  the  enlarged 
glands. 

Diagnosis.  Tonsillitis  can  hardly  be  mistaken  for  any  other 
affection  if  the  fauces  are  inspected. 

Prognosis.  In  the  majority  of  cases  the  result  is  favorable,  it 
very  rarely  proving  fatal,  except  in  children,  and  only  then  by  ob- 
structing the  respiration,  and,  at  the  same  time,  so  seriously  interfer- 
ing with  nutrition  that  the  child's  strength  fails. 

Treatment.  The  first  indication  in  an  attack  of  acute  tonsillitis 
is  a  prompt  and  efficient  purgative,  and  none  is  better  than  calomel : 

R.     Hydrarg.  chlor.  mitis, gr.  v  .3  Gm. 

Sodii  bicarbonatis,      ......  gr.  v  .3  Gm.  M. 

Ft.  chart. 

Followed  in  six  or  eight  hours  by  a  saline.  I  can  confidently  recom- 
mend sodii  salicylas,  gr.  x-xv  (0.6-1  Gm.),  every  hour  or  two  until  a 
drachm  and  a  half  to  two  drachms  are  administered.  It  should  be 
well  diluted.  Cincho7iidincE  salicylas,  gr.  v  (0.3  Gm.),  every  couple 
hours  is  often  beneficial. 

Should  the  febrile  action  be  high,  tinctura  aconiti  in  small  doses 
frequently  repeated,  either  alone  or  alternating  with  sodii  salicylas, 
rapidly  reduces  the  temperature  and  the  frequency  of  the  pulse,  and, 
by  its  local  action,  lessens  the  pain  and  swelling.  If  from  any  cause 
the  internal  use  of  aco7iitu7n  be  contra-indicated,  the  tinctura  aconiti 
may  be  diluted  with  glycerinum  and  painted  over  the  affected  parts. 

Cases  not  seen  until  two  or  three  days  after  the  onset  are  benefited 
by  the  following : 

R  .     Tincturae  ferri  chloridi, f_:^ij  8.  Cc. 

Glycerini, adf^ij  ad  60.  Cc.  M. 

SiG. — Teaspoonful  every  two  hours,  tiTidiluted. 

This  palatable  mixture,  suggested  by  Dr.  Bosworth,  acts  as  a  local 
astringent  in  passing  over  the  inflamed  tonsils,  and  should  not  be 
followed  with  water  or  food  for  an  hour  at  least. 

During  the  past  five  years  I  have  had  excellent  results  from  nuclein 
(Aulde),  gr.  j-iij  (0.065-0.2  Gm.),  or  TTLj-v  (0.065-0.3  Cc),  every  hour, . 
the  patient  sucking  pellets  of  ice,  and  having  hot  dry  applications  to 
the  angles  of  the  jaw. 

Scarification,  a  long,  sharp  bistoury  being  used  to  make  five  or  six 
18 


274  I'KACTICIC    OK    MEDICINE. 

cuts,  affords  great  relief  when  the  tonsils  are  much  inflamed  ;  the  ex- 
ternal \x'i&  of  ice  over  the  site  of  the  glands,  and  small  pellets  allowed 
to  dissolve  in  the  mouth,  afford  great  relief.  If  the  application  of 
cold  be  objectionable,  heat  may  be  substituted  in  the  form  of  warm 
compresses  or  poultices. 

In  all  cases  recourse  to  such  general  therapeutic  measures  as  are 
calculated  to  guide  the  morbid  action  to  a  favorable  issue ;  the  bowels 
should  be  kept  open  and  the  skin  and  kidneys  active  ;  the  diet 
should  be  in  the  shape  of  gruels,  as  it  is  impossible  for  the  patient 
to  swallow  any  solid  substance,  and  in  cases  where  even  gruels 
cause  painful  deglutition,  thin  oatmeal  gruel  can  be  used  with 
advantage. 

When  siippuratioti  cannot  be  averted,  hot  applications  should  be 
applied  to  the  angles  of  the  jaws,  hot  gargles  and  the  steam  atomizer 
resorted  to,  medicated  with  opium,  belladonna,  benzoin,  or  cocainae 
hydrochloras,  and  as  soon  as  fluctuation  can  be  detected  the  abscess 
should  be  opened.  Also  during  this  stage  administer  quiuittce  sulphas, 
gr.  iij-v  (0.2-0.3  Gm.)  every  three  or  four  hours.  After  the  acute 
symptoms  have  subsided,  assist  the  return  of  the  glands  to  their  nor- 
mal condition  by  the  topical  application  oi  cupri  sulphas  [gr.  xx  (1.3 
Gm.)  aquae  f5J  (30  Cc.)],  or  liquor  ferri  subsulphatis  [f3j  (4  Cc.) 
aquas  f5J  (30  Cc.)]. 


DISEASES   OF   THE   LARYNX. 


ACUTE  CATARRHAL  LARYNGITIS. 

Synonyms.     Catarrhal  laryngitis  ;  "  sore  throat." 

Definition.     An   acute  catarrhal  inflammation   of  the  mucous 

membrane  of  the  larynx  ;  characterized  by  feverishness,  diminished 

or  suppressed  voice,  painful  deglutition,  and  more  or  less  difficulty 

of  respiration. 

Causes.     Atmospherical  changes ;    cold   draughts  of  air,  either 

directly  inspired  or  an  exposure  of  parts  or  all  of  the  body.     Cold, 


DISEASES   OF  THE   LARYNX.  275 

wet  feet.  Inhalation  of  irritating  vapors,  such  as  gases,  smoke,  or 
ammonia,  or  the  inhalation  of  dust.  Prolonged  efforts  at  public  speak- 
ing or  singing  or  the  same  efforts  under  difficulties.  In  children,  from 
violent  fits  of  crying. 

Pathological  Anatomy.  In  mild  cases  there  is  a  transient 
^(^^^^//^^(hyperaemia)  of  the  mucous  membrane  over  the  entire,  but 
more  commonly  circumscribed  portions  of,  the  larynx,  with  more  or 
less  swelling  and  diminished  secretion  ;  the  mucous  membrane  soon 
returns  to  its  normal  condition,  the  secretion  being  slightly  increased. 

Symptoms.  The  attack  begins  rather  suddenly  with  a  feeling  of 
dryness,  rawness,  and  tickling,  referred  to  the  larynx  with  the  sensa- 
tion of  the  presence  of  a  foreign  body  in  the  throat,  and  with  hoarse- 
ness and  a  disposition  to  cough.  Deglutition  causes  pain  by  the 
upward  movement  of  the  larynx  and  by  the  pressure  of  the  food  on 
the  larynx  as  it  passes  along  the  gullet.  Attempts  at  speaking  are 
attended  with  more  or  less  distress  and  the  larynx  is  tender  on 
pressure. 

Coughing,  from  the  onset,  of  a  noisy,  harsh,  hoarse,  or  toneless 
character  and  the  act  of  coughing  attended  with  a  sensation  of 
scratching  in  the  larynx.  The  first  day  or  two  there  is  scanty  expec- 
toration, but  in  a  short  time  the  secretion  is  increased,  giving  the 
cough  a  loose  character.  In  the  early  stages  the  sputa  may  be 
slightly  streaked  with  blood.  Rarely  a  hemorrhage  occurs  from  the 
mucous  membrane  of  the  larynx.  The  voice  is  at  first  decidedly 
hoarse,  soon  followed  by  complete  aphonia.  The  respiration  is  but 
slightly,  if  at  all,  affected  in  adults.  There  may  be  more  or  less 
febrile  reaction.  In  children  the  onset  is  with  fever,  white  coated 
tongue,  frequent,  tense  pulse,  hot  skin  d^nd  flushed  face,  embarrassed 
respiration,  the  voice  hoarse  and  whispering,  with  harsh,  ringing, 
croupy  cough  and  great  restlessness.  During  the  night  the  child  is 
subject  to  suffocative  attacks  (laryngismus  stridulus). 

Laryngoscopic  appearances.  These  vary  with  the  severity  of  the 
attack  and  the  stage  of  the  inspection.  In  mild  cases,  at  an  early 
period,  the  mucous  membrane  presents  a  bright  red  appearance. 
Severe  cases  present,  in  addition  to  the  bright  redness,  swelling  of  the 
mucous  membrane  to  such  an  extent  at  times  as  to  conceal  the  vocal 
cords,  they  appearing  only  as  slender  threads  of  a  reddish  tint.  At 
times  the  mucous  membrane  presents  the  appearance  of  erosions  or 
ulcerations,  due  to  the  desquamation  of  the  epithelium. 


L'Tf)  PRACTICE    OF    MEDICINE. 

Duration.  Usually  about  one  week  ;  if  very  severe,  two  or  three 
Aceks  may  elapse  before  the  larynx  returns  to  its  former  con- 
dition. 

Prognosis.     Simple  catarrhal  laryngitis  never  terminates  fatally. 

Treatment.  Confinement  to  an  apartment  of  uniform  tempera- 
ture, the  air  kept  moist  by  the  vapor  of  water,  particularly  for  chil- 
dren. 

Locally,  a  hot  pack  should  be  kept  constantly  wrapped  about  the 
throat,  and  if  its  application  is  preceded  by  the  temporary  use  of  a 
weak  mustard  plaster,  the  relief  afforded  is  more  rapidly  obtained. 
At  the  very  beginning  of  an  attack  the  feet  should  be  placed  in  a  hot 
mustard  foot  bath,  and  either  2^  saline  cathartic  or  mercurial  purgative 
administered. 

Prompt  action  on  the  skin  at  the  very  onset  will  frequently  shorten 
the  duration  of  a  catarrh  of  the  larynx.  Use  for  this  purpose  in  adults 
pulvis  ipecacuanhcE  ct  opii,  gr.  iij  (0.2  Gm.),  combined  with  potassii 
tiitras,  gr.  iij  (0.2  Gm.),  every  three  or  four  hours.  If  there  be  much 
febrile  reaction,  benefit  follows  the  use  of  tinctura  aconiti,  TT\^j-ij 
(o  06-0.12  Cc),  every  half  hour  until  five  or  six  doses  are  taken,  after 
which  every  hour  or  two,  combined  with  tinctura  opii,  Ti\,j-v  (0.06-0.3 
Cc.) ;  or  diaphoresis  may  be  produced  by  antimonii  et potassii tartras, 
gr.  j'lj— sV  (0.003-0.002  Gm.),  every  hour,  or  by  the  hypodermic  injec- 
tion oi pilocarpi/icB  hydrochloras,  gr.  ^  (0.022  Gm.). 

For  children,  several  doses  of  the  following  powder  a  couple  of 
hours  apart,  until  the  bowels  are  freely  moved  : 

R .     Ilydrargyri  chloridi  mitis,  ....    gr.  ^  .008  Gm. 

Pulvis  ipecacuanhae, g*"-  /^  .008  Gm. 

Sacch.  lactis, gr-  ij  -13    Gm. 

To  be  followed  by — 

li .     Potassii  citrat., "y^'w  5.3  Gm. 

Tinct.  aconiti, Tl\,v  .3  Cc. 

Tinct.  opii  camphorat., f^ij-iv  8.-15.  Cc. 

Syr.  scillae, f.5  ij  8.  Cc. 

Syr.  tola, ad  f  5  iij  ad     90.  Cc.         M. 

SiG. — One  teaspoonful  every  two  hours. 

If  a  tendency  to  spasm  of  the  glottis  obtains,  full  doses  of  the  bro- 
mides should  be  administered  at  once. 


DISEASES   OF  THE   LARYNX,  277 

Inhalations  from  the  onset  are  not  only  soothing,  but  curative,  in 
their  actions.     Either  of  the  following  are  recommended  : 

R.     Infusihumuli, Oj  475.  Cc. 

Vinegar,      f§ss-j  15.-30.  Cc. 

SiG. — Inhale  hot  every  hour. 

U  •     Tinct.  benzoin,  comp., f  3J~y  4.-8.  Cc. 

Aquae  bullae, Oj  475.         Cc. 

SiG. — Inhale  hourly. 

The  local  application  of  cocaine  is  of  great  benefit. 

Attacks  of  acute  laryngitis  occurring  from  efforts  in  public  speaking 
or  singing  are  wonderfully  benefited  by  the  use  of  acidum  nitricum 
dilutum,  iTLij-v  (0.12-0.3  Cc),  every  hour  or  two  ;  or  atropince  sidph., 
gr.  ^^  (0.00022  Gm.),  repeated  in  an  hour  for  several  doses. 

The  patient  should  abstain  altogether  from  the  use  of  the  voice  and 
from  taking  food  or  drink  of  an  irritating  character. 


(EDEMATOUS  LARYNGITIS. 

Synonym.    Qldema  of  the  glottis. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  larynx  and  that  about  the  glottis,  with  an  infiltration  of  the  areolar 
tissues  by  a  serous,  sero-purulent,  or  purulent  fluid  ;  characterized  by 
obstructed  or  stridulous  breathing  and  dysphonia  or  aphonia. 

Causes.  The  result  of  acute  laryngitis  ;  abscess  in  or  about  the 
throat  or  tonsils  ;  erysipelas  of  the  face  ;  scarlatina  ;  small-pox ; 
Bright's  disease ;  syphilis  of  the  larynx.     Rare  in  children. 

Pathological  Anatomy.  Infiltration  into  the  loose  connective 
tissue  of  the  ary-epiglottic  folds,  the  glosso-epiglottic  ligament,  the 
base  of  the  epiglottis,  and  the  inter-arytenoid  space.  If  the  true 
vocal  cords  are  inflamed,  their  color  changes,  and  instead  of  appear- 
ing white,  glistening,  and  brilliant,  they  are  dull,  grayish-red,  or 
violet-red  in  patches.  If  the  swelling  be  the  result  of  purulent  infil- 
tration, the  parts  present  a  deeply  congested  color,  with  here  and 
there  spots  of  a  yellowish  hue. 

Serous  infiltration,  sufficient  to  cause  fatal  oedema,  disappears 
with  death,  leaving  but  slight  traces  to  account  for  the  formidable 
symptoms. 


278  PRACTICE    OF    MEDICINE. 

Syraptoms.  The  onset  is  much  the  same  as  a  simple  catarrhal 
laryngitis  with  a  gradually  increasing  inipcdivient  to  the  respiration. 

The  patient  experiences  the  sensation  of  a  foreign  body  in  the  throat, 
and  after  a  short  time  a  difficulty  of  breathing,  which  ultimately 
threatens  suffocation.  The  deglutition  is  rendered  difficult  owing  to 
the  swelling  of  the  epiglottis;  the  voice,  zX.  first  muffled,  gradually 
becomes  weaker  and  weaker,  until  finally  it  is  almost  extinct;  the 
cough  at  first  is  dry  and  harsh,  but  as  the  infiltration  increases  it 
becomes  stridulous  and  suppressed  ;  there  is  no  expectoration, except 
that  after  great  effort  to  clear  the  throat  a  little  frothy  mucus  is  raised. 
The  difficulty  of  respiration,  as  the  disease  progresses,  becomes  greater 
and  greater,  and  the  paroxysms  of  impending  suffocation  more  fre- 
quent. The  inspiration  is  accompanied  by  a  whistling  sound  char- 
acteristic of  the  narrow  condition  of  the  glottis  ;  the  patient  sits  up  in 
bed,  his  mouth  open,  gasping  for  breath,  his  eyes  protruding,  the 
whole  body  trembling  with  intense  convulsive  movements,  and  after 
a  time  a  general  cyanosis  commences,  the  face  assuming  a  bluish  hue, 
all  these  symptoms  continuing  for  a  few  moments,  when  slight  relief 
occurs,  to  be  again  followed  by  another  paroxysm,  in  one  of  which, 
if  nature  or  art  does  not  afford  prompt  relief,  death  occurs  from 
asphyxia. 

A  physical  examitiation  of  the  parts  may  be  made  by  gently  pass- 
ing the  finger  into  the  throat,  when  the  epiglottis  may  be  felt  very 
much  thickened,  and  the  ary-epiglottic  folds  may  have  attained  such 
tumefaction  as  to  convey  to  the  finger  an  impression  similar  to  that 
which  is  given  by  touching  the  tonsils. 

Laryngoscopic  appearance.  The  mucous  membrane  has  a  bright 
red  appearance.  The  epiglottis  has  the  appearance  of  a  semi-trans- 
parent roll-like  body,  or  it  is  often  merely  erect  and  tense.  It  is  this 
condition  of  the  epiglottis  which  explains  the  pain  and  difficulty  in 
deglutition.     Rarely  the  vocal  cords  are  infiltrated. 

Diagnosis.  Any  disease  which  gives  rise  to  dyspnoea  may 
simulate  oedematous  laryngitis,  but  the  history  of  the  case,  together 
with  a  laryngoscopic  examination,  will  generally  furnish  conclusive 
evidence  of  the  nature  of  the  malady. 

Prognosis.  As  a  rule,  unfavorable.  If  early  and  vigorous  treat- 
ment be  instituted,  recovery  is  possible,  but  without  it  death  is  the 
inevitable  result,  the  patient  dying  asphyxiated.  Even  when  local 
measures  have  removed  the  obstruction  to  free  respiration,  the  patient 


DISEASES   OF  THE   LARYNX.  279 

is  very  likely  to  perish  subsequently  from  exhaustion  or  blood  poison- 
ing, or  from  pneumonia  or  other  lung  complication.  The  duration  of 
infiltration  of  the  larynx  varies  from  a  few  hours  to  several  days. 

Treatment.  Prompt  local  treatment  must  be  adopted  in  order  to 
remove  the  laryngeal  obstruction.  Leeches  placed  over  the  sides  of 
the  larynx  in  mild  cases  may  effect  reduction  in  the  oedema,  rendering 
the  subsequent  progress  free  from  danger. 

If  the  infiltration  has  already  occurred  and  is  slight  in  amount, 
scarification,  guiding  the  instrument  by  the  index  finger  of  the  oppo- 
site hand,  may  afford  relief,  or  the  hypodermic  injection  oi pilocarpines 
hydrochloras,  gr.  ^  (0.022  Gm.),  repeated,  may  lessen  the  swelling. 

Niemeyer  recommends  the  persistent  use  of  small  pellets  of  ice 
early  in  the  attack,  swallowed  or  held  far  back  in  the  mouth  until  dis- 
solved. Trousseau  recommends  the  inhalation  or  spray  of  a  strong 
solution  of  acidum  tannicimt.  Prof.  Da  Costa  suggests  the  applica- 
tion, as  near  the  seat  of  the  disease  as  possible,  of  liquor  f err i  sub- 
sulphaiis  (Monsel's  solution),  full  or  half  strength.  Mackenzie  says 
the  patient  should  be  kept  constantly  under  the  influence  of  potassii 
broniidu7n. 

If  these  means  fail,  tracheotomy  is  indicated ;  in  those  cases  of 
sudden  and  rapid  infiltration  of  the  glottis  or  larynx  occurring  in 
Bright's  disease,  erysipelas,  scarlatina,  or  syphilis  of  the  larynx,  and 
especially  the  former  and  the  latter,  tracheotomy  should  be  performed 
at  once.  Intubation  relieves  the  obstructed  breathing  while  other 
means  are  combating  the  disease. 

In  all  cases  of  infiltration  of  the  larynx  stimulants  should  be  boldly 
administered  per  rectum,  if  stomachic  administration  be  impossible. 

If  the  infiltration  be  composed  oi  pus,  qtdnincB  sulphas,  gr.  v  (0.3 
Gm.)  every  four  hours,  and  stimulants  are  indicated. 


SPASMODIC  LARYNGITIS. 

Synonyms.     Spasmodic  croup ;    false  croup ;    catarrhal  croup ; 

child  crowing. 

Definition,  A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  larynx,  associated  with  temporary  spasmodic  contraction  of  the 
glottis ;  characterized  by  paroxysmal  coughing,  difficulty  of  breathing, 
and  attacks  of  threatening  suffocation. 


280  PRACTICE    OF    MEDICINE. 

Causes.  Atmospherical  changes  or  "taking  cold";  excesses  in 
eating  and  drinking;  excitement;  violent  emotion,  are  all  given  as 
causes  for  simple  croup. 

Pathological  Anatomy.  Congestion  of  the  mucous  membrane 
of  the  larynx,  with  slight  swelling  and  deficient  secretion,  are  the 
only  changes  that  have  thus  far  been  noted. 

Symptoms.  The  attack  occurs  chiefly  during  the  night,  the 
child  on  retiring  having  either  its  usual  health,  or  perhaps  being 
a  little  feverish.  After  several  hours  of  sleep  the  child  is  suddenly 
awakened  by  a  paroxysm  of  suffocation,  and  a  dry,  harsh,  ringing 
cough.  After  half  an  hour  or  an  hour  or  two  the  breathing  becomes 
easier,  the  cough  less  "croupy,"  the  skin  is  covered  with  more  or  less 
perspiration,  and  the  child  falls  asleep.  The  next  day  there  is  present 
cough  of  a  loose  character,  the  respiration  being  about  normal.  If 
no  treatment  be  instituted,  the  same  phenomena  occur  on  the  second 
night,  the  child  being  apparently  well  during  the  second  day.  the 
cough  being  less  in  amount ;  phenomena  of  a  similar  character,  but 
of  much  less  severit)\  are  present  the  third  night,  after  which  the  dis- 
ease usually  disappears. 

If  the  symptoms  of  the  first  paroxysm  continue  pronounced  for  two 
or  three  days,  there  is  a  strong  probability  that  the  inflammatiori  may 
become  fibrinous  in  character,  or  that  true  croup  may  develop. 

Diagnosis.  The  symptoms  are  so  characteristic  that  it  seems 
impossible  for  the  affection  to  be  mistaken  for  any  other  disease. 

F^TOgrnosis.  Spasmodic  or  simple  croup  always  terminates  favor- 
ably. 

Treatment.  During  the  paroxysm,  the  child  should  at  once  be 
placed  in  a  hot  bath  and  hot  or  cold  compresses  vixn^^&dL.  about  the 
throat.  These  means  should  be  preceded  or  followed  by  a  mild 
emetic.  The  late  Chas.  D.  Meigs  always  used  aluviinis,  with  or  with- 
out syrtipus  ipecactianhce ;  Prof.  Bartholow  recommends  hydrargyri 
siibsuiphas  flavus  (turpeth  mineral)  gr.  j-iij  (0.065-0.2  Gm.);  Prof. 
Da  Costa  suggests  the  cautious  use  of  apojnojphincB  hydrochloras, 
gr.  ^  (0.006  Gm.),  hypodermically.  A  favorite  remedy  for  emesis, 
in  Germany,  when  the  jaws  are  not  closed,  and  one  that  is  highly 
successful,  is  tickling  the  fauces  with  the  finger  or  a  feather  until 
vomiting  is  produced.  Inhalations  of  chloroformum  often  at  once 
relieve  the  spasms,  but  must  never  be  employed  by  non-professional 
persons.     Having  by  any  of  the  above  means  broken  up  the  spasm 


•  s 

Cc. 

6. 

Cc. 

12. 

Cc. 

90. 

Cc. 

DISEASES   OF  THE   LARYNX.  281 

of  the  larynx,  a  prompt  cathartic  should  be  administered  (R.  Hydrar- 
gyri  chloridi  mitis,  gr.  ij  (o.  13  Gm.),  sodii  bicarbonatis,  gr.  iij  (0.2  Gm)., 
M.  et  ft.  chart,  no.  j),  followed  in  six  to  eight  hours,  if  not  sufficient 
results,  with  oleum  ricini,  after  which  : 

R .     Tincture  aconiti, TT\,'^^U 

Syr.  ipecacuanhge, f^iss 

Tincturre  opii  camphorat.,     .    .    .  f^iij 

Liquor  potassii  citratis,  .    .    .      ad  f^  iij  ad     90.       Cc.  M. 

SiG. — One  teaspoonful  every  hour  or  two. 


CROUPOUS  LARYNGITIS. 

Synonyms.     Membranous  croup  ;  true  croup. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  larynx,  attended  with  the  exudation  of  a  tough  secretion — the 
false  membrane — and  the  occurrence  of  spasm  of  the  glottis  ;  charac- 
terized by  febrile  reaction,  frequent  ringing  cough,  dyspnoea,  with 
loud  respiratory  sound,  and  altered  or  extinct  voice,  showing  a  strong 
tendency  toward  death  by  asphyxia. 

Causes.  A  disease  of  childhood,  most  common  in  strong,  vigor- 
ous, well-nourished  males.  Certain  families  present  a  strong  heredi- 
tary tendency.     Most  common  during  a  humid  winter. 

We  cannot  assent  to  the  dictum  of  some  authorities,  that  laryngeal 
diphtheria  and  croupous  laryngitis  are  identical. 

Pathological  Anatomy.  Intense  hypercetnia  of  the  mucous 
membrane  of  the  larynx,  associated  with  swelling,  oedema,  and  marked 
redness.  There  soon  appears  on  the  surface  of  the  mucous  mem- 
brane a  grayish  pellicle,  rapidly  coalescing  and  becoming  thicker, — 
the  opaque,  false  membrane, — which  differs  in  extent,  thickness,  and 
adhesiveness  in  different  portions  of  the  larynx.  In  all  cases  the 
false  membrane  is  found  on  the  vocal  cords  and  inner  surface  of  the 
epiglottis.  The  first  exudation  (membrane)  softens  by  the  serum 
which  is  exuded,  and  is  then  mechanically  dislodged  by  acts  of 
coughing  or  vomiting,  but  is  followed  by  successive  deposits  upon  the 
mucous  membrane. 

When  the  false  membrane  is  detached,  the  mucous  membrane  of 
the  larynx  is  found  unaffected,  so  far  as  the  loss  of  structure  is  con- 
cerned.    Several  successive  crops  of  membrane  may  form  after  the 


282  PRACTICF.    OF    MEDICINF.. 

detachment,  or  it  may  entirely  cease  to  form  after  the  removal  of  the 
first  exudation. 

<dv\  viicroscopical examination  the  false  membrane  is  found  to  be 
composed  of  a  fine  network  of  fibrilhc,  holding  in  their  interstices 
leucocytes  of  an  albuminous  or  fibrinous  nature. 

The  false  membrane  may  extend  into  the  pharynx,  but  especially 
is  it  liable  to  extend  into  the  trachea  and  bronchial  tubes,  and,  as  the 
inflammation  extends  downward,  the  character  of  the  exudation 
changes  from  fibrinous  to  mucopurulent. 

Symptoms.  The  onset  of  "true  croup"  is  either  suddenly,  by 
an  attack  of  spasmodic  croup,  or  gradually,  as  an  acute  catarrh  of 
the  larynx,  rapidly  increasing  in  severity,  with  a  feeling  o^  hcai'xw  the 
throat,  huskiness  of  the  voice,  harsh  cottgh,  fever,  and  thirst,  the 
hoarseness  soon  becoming  marked,  and  the  cough  having  a  metallic, 
"  crotipy"  character,  rapidly  changing  io  a  stridulous,  husky  sound; 
every  few  minutes  the  child  takes  a  sudden,  deep,  stridulous  inspira- 
/w«,the  voice  becoming  more  and  more  husky.  DiJJiculiy  of  breath- 
ing xiO'Oi  follows;  the  child  is  unable  to  lie  down,  or  if  exhausted  by 
the  efforts  at  inspiration,  it  is  quiet  for  a  moment,  it  soon  starts  up  in 
fright,  breathing  more  heavily,  with  a  shrill,  "whistling  inspiration. 
Soon,  from  the  narrowing  of  the  glottis,  from  the  presence  of  the 
membrane,  the  expiration  becomes  difficult  and  noisy,  and  suffocation 
seems  imminent  from  the  paroxys/nal  attacks  of  spasm  of  the  glottis  ; 
the  child  tosses  wildly  about,  tears  at  its  throat,  as  if  to  remove  some 
obstacle,  the  face  becoming  cyanosed,  the  alae  of  the  nose  working 
rapidly,  the  mouth  wide  open,  the  inspiratory  efforts  gasping,  the 
body  covered  with  a  profuse  sweat,  and  death  seems  imminent,  when, 
suddenly,  the  spasm  is  relaxed,  air  enters  the  chest,  the  breathing  be- 
comes somewhat  easier,  and  the  child,  exhausted  and  partially  stupe- 
fied, drops  into  a  fitful  sleep  of  a  few  moments'  duration. 

The  suffocative  attacks  return  at  short  intervals,  or  there  occur 
decided  remissions  between  them,  considerable  portions  of  the  false 
membrane  being  expelled,  allowing  the  child  to  fall  into  a  refreshing 
sleep. 

In  those  cases  which  tend  to  a  favorable  termination,  the  appear- 
ance of  improvement  noted  between  the  suffocative  attacks  is  main- 
tained, the  paroxysms  of  suffocation  becoming  less  frequent,  the 
expectoration  of  membrane  more  marked,  the  difficulty  of  breathing 
lessens,   the   cough   loosening,  the   voice   gradually    returning,   the 


DISEASES   OF  THE   LARYNX.  283 

fever,  which  has  been  more  or  less  high  during  the  attack,  disap- 
pearing. 

If,  instead  of  improvement,  the  case  tends  toward  a  fatal  termina- 
tion, the  suffocative  attacks  become  more  frequent,  expectoration  is 
absent,  the  voice  and  cough  inaudible,  although  the  efforts  at  speak- 
ing and  coughing  are  visible,  the  difficulty  of  breathing  continues,  the 
respirations  becoming  more  frequent  and  shallow,  but  without  whist- 
ling and  stridor,  the  cyanosis  deepens,  the  countenance  has  an  indif- 
ferent, drowsy,  and  stupid  look,  the  eyes  dull  and  nearly  closed,  with 
symptoms  of  depression,  the  pulse  rapid  and  weak,  the  surface 
covered  with  a  cold,  clammy  sweat,  the  extremities  cold,  stupor  and 
insensibility  more  marked,  the  child  dying  of  carbonic  acid  poisoning 
or  asphyxia. 

Duration.  The  duration  of  true  croup  is  about  one  week,  rarely 
continuing  ten  days. 

Diagnosis.  (Edema  of  the  glottis  might  be  mistaken  for  croup 
until  the  period  of  the  formation  of  the  characteristic  membrane. 
The  chief  points  of  distinction  from  the  onset  are,  however,  absence 
of  fever,  paroxysmal  attacks  of  difficult  respiration,  followed  by  a 
complete  return  to  the  normal  condition.  CEdema  of  the  glottis  is 
rare  in  childhood. 

The  following  are  the  chief  points  of  difference  between, croup  and 
laryngeal  diphtheria : 

Croup.  Diphtheria. 

A  local  disease.  A  constitutional  disease. 

Begins  in  trachea  and  extends  up.  Begins  at  tonsils  and  extends  down. 

Exudation  never  cutaneous.  Exudation  often  cutaneous. 

Kg  pain  in  swallowing.  Often  severe  pain  in  swallowing. 

No    swelling    of    submaxillary    and  Swelling  of  submaxillary  and  lymph- 
lymphatic  glands.  atic  glands. 

Cough  always  present  and  often  re-  Seldom  much  cough   and  then  only 
duced  to  a  mere  whistle  with  pecu-  hoarse. 

liar  metallic  ring. 

Not  traceable  to  bad  drainage.  Often  traceable  to  bad  drainage. 

Seldom  occurs  in  adults.  Often  occurs  in  adults. 

Neither  contagious  nor  infectious.  Both  contagious  and  infectious,  both 

before  and  after  death. 

A  sthenic  disease.  An  asthenic  disease. 


284  practice  of  medicine. 

Croup.  Diphtheria. 

Membrane  does  not  extend  to  nares.       Often   extends   to   nares   and    manj 

other  parts. 
No  symptoms  of  septicaemia.  Seplica.'mia  generally  present. 

No  albuminuria.  Albuminuria  frequent. 

Neither  attended  with  nor  followed       Paralysis  not  uncommon. 

by  paralysis. 
Death  seldom  caused  by  syncope.  Death  from  syncope  common. 

Death  due  to  suffocation.  Death  frequently  results  from  other 

causes. 
Absence  of  a  specific  germ.  PresenceoftheKlebs-LoefTlerbacillus. 

Prognosis.  A  very  fatal  disease.  The  danger  increases  in  pro- 
portion to  the  age  and  feebleness  of  the  child.  Intubation  has  won- 
derfully lessened  the  mortality  in  croup. 

Unfavorable  symptoms  are  :  Loud,  stridulous,  inspiratory,  and  expi- 
ratory sounds,  laborious  and  prolonged  expiration,  depression  of  the 
base  of  the  thorax  during  inspiration,  whispering  voice  or  complete 
aphonia,  congestion  of  the  face  and  neck,  stupor,  weak,  rapid,  and 
irregular  pulse,  cold  extremities,  and  a  cold,  clammy  perspiration. 

Favorable  symptoms  are :  Expectoration  of  false  membrane,  de- 
crease of  the  stridulous  respiration,  voice  changing  from  whispering 
to  hoarseness,  looseness  of  the  cough,  moderation  of  the  fever,  and 
an  improvement  in  the  general  condition. 

Treatment.  The  indications  for  treatment  are  to  detach  and 
remove  the  false  membrane,  to  prevent  its  reformation,  to  prevetit  the 
attacks  of  spasm  of  the  glottis,  and  to  maintain  the  strength. 

To  detach  and  remove  the  membrane  emetics  are  of  the  highest 
utility,  the  favorite  of  this  class  being  the  one  first  used  in  this  disease 
by  Dr.  Fordyce  Barker,  consisting  of  hydrargyri  subsulphas  fla^nis 
(tiirpeth  mineral),  gr.  ij  (0.13  Gm.)  for  a  child  of  two  years  of  age, 
repeating  the  dose  as  often  as  rendered  necessary  by  the  obstructed 
breathing;  but  the  unnecessary  administration  of  emetics  should  be 
avoided,  as  the  strength  of  the  patient  must  be  maintained. 

To  prevent  the  formation  of  the  membranous  exudation  a  number 
of  remedies  have  been  recommended  and  highly  lauded,  but  hydrar- 
gyrum is  the  only  one  that  has  stood  the  test  of  experience  ;  it  may 
be  used  as  hydrargyri  chloridum  corrosivum,  gr.  -^^^^  (o.ooi  5-0.003 
Gm.)  every  two  or  three  hours,  or  in  the  following  formula : 


DISEASES   OF  THE   LARYNX.  285 

R.      Hydrargyri  chloridi  mitis,     ..    .    .  gr.  i^-i^-^  .Oo8-.oi6-.032Gm. 

Sodii  bicarbonatis,       gr.  ij.  -13    ^^■ 

Pulvis  ipecacuanha,        S^-  T2~k  .005-011  Gm.  M. 

SiG. — One  powder  every  two  hours. 

Prof.  Da  Costa  has  suggested  either  of  the  following  combinations  : 

R .     Antimonii  sulphurati, gr-  ^  -OoS  Gm. 

Pulv.  ipecacuanhse  at  opii,     .    .    .  gr-  /^  -032  Gm.  M. 

SiG. — In  powder  every  two  hours. 

Or— 

B .     HydrargjTi  chloridi  mitis,      .    ,    .  gr.  y^  .008  Grn. 

Pulvis  ipecacuanhse  et  opii,   .    .    .  gr.  j^  .032  Gm.  M. 

SiG  — In  powder  every  two  hours. 

Antimonu  et  potassii  tartras,  a  remedy  that  some  years  ago  was 
popular  in  large  doses,  is  again  brought  forward  in  doses  of  gr. 
g^Q  2V  (0-002-0.003  Gm.).  Quinina:  sulphas,  gr.  v.  (0.3  Gm.)  every 
three  hours  until  six  doses  have  been  taken,  if  given  before  the 
exudation  has  formed,  it  is  claimed  will  prevent  its  formation.  It  can 
be  used  by  suppository. 

To  prevent  the  paroxysms  of  spasm,  small  doses  of  opium  in  the 
form  oi  pulvis  ipecacuanhce  et  opii  (Dover's  powder),  or  full  doses 
of  the  bromides,  preference  being  given  to  ammonii  bromidum,  as 
suggested  by  Prof.  Bartholow,  on  account  of  its  being  "  eliminated  by 
the  bronchial  and  faucial  mucous  membrane,  thus  acting  locally." 

To  maintain  the  strength  of  the  patient,  alcoholic  stijuulants  in  full 
doses,  nutritious  but  easily  digested  aliftient,  strychnifice  sulphas  in 
tonic  doses,  and  ammonii  carbonas,  are  particularly  indicated. 

As  soon  as  emesis  has  subsided,  intubation  should  be  practised. 

Locally,  the  use  of  all  caustic  or  irritating  applications  to  the  fauces 
or  larynx  is  emphatically  contraindicated. 

The  inhalation  of  the  vapor  of  slaked,  freshly  burned  lime  is  one 
of  the  most  ready  and  efficient  means  for  assisting  in  the  detachment 
of  the  false  membrane.  The  application  of  cold  or  hot  compresses, 
according  to  the  feelings  of  the  patient,  around  the  throat,  have  a 
strong  tendency  to  prevent  the  recurrence  of  the  spasms.  After  the 
formation  of  the  membrane,  great  relief  follows  the  use  of  the  vapcr 
inhalations  and  of  oxygen  gas,  which,  with  stimulants  and  liquid 
nourishment,  may  safely  carry  the  patient  through  the  disease.     Cases 


28G  PRACTICE    OF    MEDICINE. 

in  which  the  membrane  presents  a  tendency  to  slowly  loosen  itself,  if 
the  patient's  strength  does  not  contraindicate  it,  are  greatly  benefited 
by  the  application  of  stna/>is,  or  even  small  Jlying-blistcrs,  to  the 
larynx.  Inhalations  of  oxygen  have  seemed  useful  in  several  cases, 
as  has  the  internal  use  of  hydrogen  dioxiditm. 

Niemeyer  advises,  in  cases  showing  carbonic  acid  poisoning  from 
obstruction  of  respiration  due  to  accumulation  of  membrane,  the 
pouring  from  a  moderate  height  of  a  few  gallons  of  cold  water  over 
the  head,  nape,  and  back  of  the  child  ;  the  shock  produced  always 
causes  it  to  revive  for  a  while,  and  to  cough  vigorously,  thus  expecto- 
rating large  quantities  of  the  membrane,  but  this  procedure  will  become 
obsolete  in  proportion  as  intubation  is  practised. 

Ifthe  exudation  still  continues,  regardless  of  the  means  employed, 
the  propriety  of  tracheotomy  must  be  determined. 


LARYNGISMUS  STRIDULUS. 

Synonyms.  Spasm  of  the  glottis ;  pseudo-croup ;  Millar's 
asthma  ;  thymic  asthma  :  "  Kopp's  asthma"  ;  tetany. 

Definition.  A  spasm  of  the  muscles  of  the  larynx  innervated  by 
the  inferior  or  recurrent  laryngeal  nerves  ;  characterized  by  a  sudden 
development  of  dyspnoea  and  the  appearance  of  deficient  oxygena- 
tion of  the  blood. 

MacKenzie  describes  it  as  "  a  form  of  convulsion  occurring  in 
ill-nourished  infants,  characterized  by  spasmodic  action  of  the  abduc- 
tors of  the  vocal  cords,  and  in  severe  cases  by  spasm  of  the  diaphragm 
and  intercostal  muscles." 

Causes.  Most  common  in  children,  the  result  of  teething,  laryn- 
gitis, indigestion,  scrofula,  or  other  cachexiae.  Attacks  in  adults  are 
not  uncommon.     It  is  often  hereditary. 

Pathological  Anatomy.  Death  the  result  of  spasm  of  the 
glottis  is  such  a  very  rare  occurrence  that  the  changes  in  the  larynx 
are  not  determined. 

The  mechanism  consists  in  an  irritation  of  the  superior  laryngeal 
nerve, — the  afferent  nerve, — whose  function  is  to  supply  the  mucous 
lining  of  the  larynx  with  sensibility,  whence  is  reflected  through  the 
inferior  laryngeal  nerve — the  efferent  nerve — the  motor  influence 
resulting  in  the  spasm  of  the  laryngeal  muscles. 


DISEASES   OF  THE   LARYNX.  287 

Symptoms.  The  spasm  of  the  laryngeal  muscles  is  of  sudden 
onset,  and  usually  after  nightfall.  The  child  may  have  been  in 
perfect  health,  to  all  appearances,  on  retiring,  or  it  may  have  shown 
symptoms  of  catarrh  of  the  upper  air  passages,  or  been  suffering  from 
gastro-intestinal  or  dental  irritation. 

The  child  awakes  suddenly,  coughing  in  a  metallic,  resonant  tone — 
the  crotipy  cough — and  with  great  dyspncea,  with  loud,  crowhig, 
stridulous  inspirations,  the  result  of  narrowing  of  the  larynx  from 
spasm,  with  wheezy,  stridulous  expirations. 

The  entrance  of  air  is  so  greatly  obstructed  that  all  the  accessory 
muscles  of  respiration  are  called  into  use ;  the  lips  and  finger  nails 
become  blue,  the  surface  cold,  the  countenance  anxious,  and  the 
inferior  portion  of  the  chest  is  drawn  in,  instead  of  being  expanded, 
during  inspiration.  General  convulsions  occur  at  times,  during  a  par- 
oxysm, also  strabismus,  and  involuntary  discharge  of  the  faeces  and 
the  urine. 

The  paroxysm  continues  from  half  an  hour  to  an  hour  or  more,  to 
return  after  a  few  hours'  sleep  or  during  the  following  night ;  the 
cough,  during  the  day,  having  the  croupy  character. 

Diagnosis.  The  non-febrile  and  distinctly  intermittent  nature  of 
the  affection  differentiates  it  from  croup,  and  its  own  distinctive  char- 
acters from  all  other  diseases.  The  view  is  gaining  that  it  is  a 
variety  of  tetany. 

Prognosis.  Favorable.  Death  from  suffocation  during  the  par- 
oxysm may  occur  in  very  young  children,  but  it  is  certainly  a  very- 
rare  termination. 

Treatment.  For  Xht.  paroxys7n,  the  inhalation  of  a  few  drops  of 
chloroformum  is  the  most  prompt  method,  care  being  exercised,  as 
complete  anaesthesia  is  unnecessary.  Success  is  reported  from  the 
prompt  inhalation  oi  amylnitris,  also  from  niiro-glycerinum,  in  small 
but  frequently  repeated  doses.  The  following  combination  is  a  prompt 
antispasmodic : 

U.     Potassii  bromidi, gij  8.  Gm. 

Chloral, gr.  xxxij  2.  Gm. 

Syr.  aurantii  cort. , f  _^  j  30.  Cc. 

Aquce  menth., f 2J  30.  Cc. 

SiG. — One  teaspoonful  every  half  hour. 

After  the  paroxysm  has  been  suspended  by  the  above  combination, 
the  tendency  to  a  recurrence  of  the  attacks  is  prevented  by  the  steady 


2S8  PRACTICE   OF    MEI>ICINE. 

and  continued  use  oi potassii  bromiduvi,  in  moderate  doses.  Emetics 
are  often  useful  in  suspending  an  attack,  especially  if  it  be  due  to 
indigestion. 

Mackenzie  advises  the  use  of  musk  during  the  attack  if  the  child 
can  swallow  ;  and  if  not,  then  as  soon  as  the  child  can  take  it,  and 
continued  at  intervals  for  a  day  or  two.     His  formula  is  as  follows: 

li .     Moschi, gr.  iss  .10  Gm. 

Saccli.   alb., g""-  'j  -IJ  ^n\. 

Pulv.  acacise, g""-  'j  •^'3  Gm. 

Syr.  aurantii  flor., 

Aquam, aa  ad  f^j  aa       4.         Cc. 

SiG. — A  dose. 

The  high  price  of  musk,  however,  prohibits  its  general  use. 

Locally,  the  hot,  alternating  with  the  cold  pack,  should  be  constantly 
applied  to  the  throat. 

The  air  of  the  room  should  be  moistened  by  the  vapor  of  hot  water 
constantly  disengaged  in  it. 

After  the  attack  has  passed  off,  the  general  condition  of  the  child 
requires  attention  ;  for  this  purpose  it  is  well  to  administer  a  dose  of 
hydrargyri  chloridiim  mite,  to  be  followed  by  a  dose  of  oleum  ricini 
or  inagnesii  carbonas.  The  diet  must  be  regulated,  all  farinaceous 
articles  being  absolutely  forbidden. 


TUBERCULOUS  LARYNGITIS. 

Synonyms.     Laryngeal  phthisis  ;  throat  consumption. 

Definition.  An  inflammation,  tending  to  ulceration,  of  the  tissues 
of  the  larynx,  of  tuberculous  origin  ;  characterized  by  pain  on  deglu- 
tition, cough,  weakness  of  voice,  and  progressive  emaciation,  asso- 
ciated with  hectic  fever. 

Causes.  An  infection  of  the  larynx  with  the  bacillus  tuberculosis, 
either  from  the  inspired  air  or  by  the  sputum.  A  depressed  state  of 
the  system  is  essential  for  the  action  of  the  bacilli. 

Pathological  Anatomy.  It  is  well  to  remember  that  all  chronic 
inflammations  of  the  larynx  associated  with  pulmonary  tuberculosis 
are  not  tubercular. 

Begins  with  redness  of  the  mucous  membrane,  showing  scattered 
tubercles.     The  tubercles  show  a  strong  tendency  to  cluster,  then 


DISEASES   OF  THE  LARYNX.  289 

soften,  leaving  shallow,  irregular  ulcers.  The  ulcers  are  covered  with 
a  grayish  exudate.  The  mucous  tissue  round  about  the  ulcers  is 
thickened.  The  ulcers  may,  and  generally  do,  erode  the  true  vocal 
cords,  often  entirely  destroying  them.  The  ulcers  slowly  extend  in 
all  directions,  destroying  the  tissues  attacked.  The  epiglottis  may  be 
entirely  destroyed. 

Symptoms.  Usually  develops  secondary  to  pulmonary  symp- 
toms ;  rarely  it  may  occur  as  a  primary  disease,  to  be  followed  with 
tuberculosis  of  the  lungs.  The  first  symptom  is  a  change  in  the 
voice — huskiness ;  this,  associated  with  symptoms  of  ill  health,  is 
always  a  warning  to  the  physician.  The  husky  voice  may  proceed 
until  it  is  but  a  painful  whisper.  Cough  of  an  irritating,  painful 
character  associated  with  slight  expectoration.  Painful  and  difficult 
degbdiiion  (dysphagia)  is  a  very  constant  and  distressing  symptom. 
There  is  the  remitting  fever  so  characteristic  of  tuberculosis,  with 
night  sweats,  loss  of  appetite,  loss  of  flesh,  and  insomnia. 

Laryngoscopic  examination  reveals  the  characteristic  broad,  shal- 
low, irregular,  grayish  ulcers,  with  the  thickened  surrounding  mucous 
membrane.  The  vocal  cords  show  infiltration  and  thickening  or 
ulceration. 

Diagnosis.  To  discriminate  from  non-tubercular  laryngitis,  ex- 
amine the  sputum,  and  if  the  specific  bacilli  are  found,  the  diagnosis 
is  conclusive. 

Prognosis.    Unfavorable. 

Treatm,ent.  Remember  that  tubercular  laryngitis  is  not  always 
preceded  by  pulmonary  phthisis,  but  in  a  fair  proportion  of  cases  is  a 
primary  disease.  Much  can  be  done  to  make  the  patient  comfort- 
able. The  application  of  twenty,  forty,  or  even  sixty  per  centum 
solution  of  acidutn  lacticum  is  a  very  successful  remedy.  Cocaince 
hydrochloras  applied  directly  to  the  ulcers  gives  relief  to  the  pain  and 
dysphagia.  Local  applications  of  hydrogen  dioxidum,  argenti  nitras, 
and  menthol  are  of  value.  Curetting  the  ulcers  and  applying  iodo- 
formum  in  emulsion  or  with  tnorphincB  sulphas  has  been  practised 
with  benefit. 

The  general  condition  must  be  treated,  the  diet  liquid  and  of  a  most 
nourishing  character. 


19 


290  PRACTICE    OK    MliUlClNK. 


DISEASES  OF  THE  BRONCHIAL  TUBES. 


ACUTE  BRONCHITIS. 

Synonyms.  Bronchial  catarrh  ;  acute  bronchial  catarrh  ;  "cold 
on  the  clicst." 

Definition.  An  acute  catarrhal  inflammation  of  the  bronchial 
tubes  of  the  larger,  middle,  and  third  size ;  characterized  by  fever, 
substernal  pain,  a  feeling  of  thoracic  constriction,  oppression  in 
breathing,  and  at  first  scanty,  followed  by  more  or  less  profuse, 
expectoration. 

Causes.  Most  frequent  in  childhood,  especially  during  the  period 
of  dentition,  when  there  exists  a  strong  tendency  to  catarrh  of  the 
mucous  membranes  in  general  and  of  the  bronchi  in  particular.  In 
old  age  the  predisposition  again  returns.  Inhalations  of  irritants  such 
as  dust,  smoke,  and  air  too  hot  or  too  cold.  More  common  in  cli- 
mates characterized  by  considerable  moisture  of  the  atmosphere, 
combined  with  a  low  temperature,  and  especially  where  there  are 
sudden  and  marked  variations.     A  specific  germ  ? 

Pathological  Anatomy.  Hypcraviia  of  the  mucous  mem- 
brane of  the  bronchial  tubes,  manifested  by  a  diffused  redness,  swell- 
ing, oedema,  and  diminished  secretion,  followed  by  an  increased 
secretion  and  overgrowth  and  desquamation  of  the  epithelial  cells, 
together  with  a  copious  generation  of  young  cells,  the  expectoration 
then  becoming  of  a  yellowish  color  (mucopurulent).  As  a  result  of 
the  hyperaemia,  rupture  of  the  capillaries  of  the  mucous  membrane 
frequently  occurs,  when  the  slight  expectoration  of  the  first  stage  is 
streaked  with  blood. 

In  cases  of  bronchitis  following  the  exanthemata,  or  in  scrofulous 
patients,  the  bronchial  glands  participate  in  the  inflammation, 
becoming  hyperaemic,  swollen,  and  filled  with  secretion,  and  not 
mfrequently  the  glandular  elements  undergo  a  hyperplasia,  and 
finally  the  "  cheesy  "  degeneration. 

Symptoms.  The  itivasion  is  usually  characterized  by  the  occur- 
rence of  either  nasal  or  laryngeal  catarrh,  or  both,  the  patient  feeling 


DISEASES   OF  THE   BRONCHIAL  TUBES.  291 

chilly,  followed  by  flushes  of  heat;  the  limbs,  joints,  and  even  the 
body,  are  affected  with  pain  of  an  aching,  contused  character,  and 
with  a  sense  of  fatigue  and  want  of  energy ;  there  may  be  a  furred 
tongue,  anorexia,  and  constipation. 

In  nervous,  irritable  persons,  and  in  children,  there  may  be  slight 
delirium,  and  often  in  very  young  children,  especially  during  the 
period  of  dentition,  convulsions  may  usher  in  an  attack. 

After  a  day  or  two  of  these  initiatory  symptoms,  those  characteristic 
of  bronchial  catarrh  develop. 

Pain  is  experienced  beneath  the  sternum,  especially  toward  its  upper 
.  part,  of  a  raw,  bursting,  or  tearing  character,  aggravated  by  a  deep 
inspiration  or  by  coughing ;  the  pain  also  radiates  toward  the  sides, 
following  the  course  of  the  primary  bronchial  tubes.  Tenderness 
over  the  sternum  is  often  experienced.  Muscular  pain  and  tender- 
ness of  rheumatic  character  are  often  associated  with  attacks  of  bron- 
chitis. 

Cough  from  the  onset,  at  first  in  paroxysms  of  a  hard,  dry  character, 
changing  as  the  disease  progresses,  and  becoming  looser,  followed 
\yY  free  expectoration.  The  expectoratio7i  at  first  is  small  in  quantity, 
almost  transparent,  frothy,  and  having  a  salty  taste,  often  streaked 
with  blood.  As  the  disease  progresses  it  becomes  more  abundant, 
of  a  yellowish  or  a  greenish-yellow  color,  and  of  a  tenacious  con- 
sistency. 

There  are  present  slight  fever,  hot,  dry  skin,  frequent /zi^/^i?,  loss  of 
appetite,  moderate  thirst,  and  constipation. 

A  feeling  of  languor  and  weariness,  and  often  considerable  de- 
pression, quite  out  of  proportion  to  the  febrile  state,  are  not  in- 
frequent. 

Percussion.  Normal,  except  in  those  rare  cases  in  which  the 
bronchial  glands  are  involved,  when  irregular  spots  of  dullness  can 
be  developed. 

Auscultation.  First  Stage :  The  bronchial  membrane  being 
swollen  and  dry,  the  respiratory  murmur  is  harsh  or  vesiculo-bronchial 
in  character,  associated  with  diffused  sonorous  and  sibilatit  rales. 

Second  Stage  :  The  secretion  from  the  bronchial  mucous  membrane 
being  increased,  the  respiratory  murmur  is  less  harsh  in  character, 
but  is  associated  with  large  and  small  moist  or  bubbling  rales. 

Diagnosis.  The  points  of  resemblance  and  difference  between 
acute  bronchitis  and  other  diseases  of  the  chest  will  be  pointed  out 


2'J2  PRACTICE   OF    MEDICINE. 

when  those  affections  are  described.  The  association  of  bronchitis 
with  other  diseases  must  not  be  forgotten. 

Prognosis.  Acute  bronchitis  of  the  larger  tubes  usually  termi- 
nates in  complete  resolution  within  two  weeks.  In  children  and  in  the 
aged  the  course  is  more  protracted,  and  the  symptoms  more  severe, 
but  recovery  is  the  rule.  Very  aged  and  feeble  persons  may  succumb, 
but  it  is  rare. 

Treatment.  Depends  upon  the  stage  when  seen.  During  the 
invasion,  quinina:  sulphas,  gr.  x  (0.6  Gm.),  combined  with  tnorphina 
sulph.,  gr.  Y^  (o.oi  I  Gm.),  will  usually  prevent  or  abort  an  attack  of 
acute  bronchitis. 

In  the  first  stage,  in  adults,  when  the  mucous  membrane  is  swollen 
and  dry,  either  of  the  following  prescriptions  will  give  prompt  relief: 

li.     Antimonil  et  potassii  tart.,     .    .    .    jjr.  ij  .13  Gm. 

Liquor,  ammonii  acetatis,      .    .    .  fSiv  120.       Cc. 

Spts.  Klheris  nitrosi, f^^j  30.       Cc. 

(Tinct.  aconiti,  if  indicated),    .    -f^ss  2.       Cc. 

Syr.  simplicis, adf^vj  ad  180.       Cc.  M. 

SiG. — Two  teaspoonfuls  every  two  or  three  hours. 

Or— 

R.     Vini  ipecacuanhre, fzj 

Liq.  potassii  citrat., f5''j 

Liq.  ammonii  acetat., fo''J  9°-       ^*--  ^^' 

SiG. — Tablespoonful  every  two  or  three  hours. 

If  the  cough  of  the  dry  stage  be  severe,  or  if  the  looseness  of  the 
bowels  follow  the  use  of  either  of  the  above  combinations,  tinctura 
opii  caviphorata  may  be  added  with  advantage,  or  codeina,  but  use 
opium,  with  caution,  in  the  dry  stage.  Tinctura  Jiyoscyami,  n^v-xv 
0.3-1  Cc.)  is  much  better. 

For  young  children  the  above,  in  proportionately  reduced  doses,  or 
the  following ; 

U.     Pulv.  ipecac,  et  opii, gr-  v  .3    Gm. 

Pulv.  scilla;, gr-  x  .6    Gm. 

Hydrargyri  clilor.  mitis,    .    .    .    .  gr.  ij  .13  Gm. 

Sacch.  lact., gr.  x  .6    Gm.  M. 

Ft.  chart.  No.  x. 

SiG. — One  every  two  hours. 


4- 

Cc. 

90. 

Cc. 

90. 

Cc. 

DISEASES   OF   THE   BRONCHIAL   TUBES.  293 

The  following  is  an  excellent  mixture  for  children  : 

U-     Potassii  citrat. , ^ij  8.  Gm. 

Syr.  ipecac, fgij  8.  Cc. 

Syr.  scillce, i^j  4.  Cc. 

Syr.  limonis, f^'j  8-  ^^• 

Tinct.  opii  camphorat., fgij  8.  Cc. 

Elix.  simplicis, ad  f  ^  iij  ad  90.  Cc.  M. 

SiG. — Teaspoonful  every  couple  hours. 

Locally :  Hot  mustard  foot  bath,  and  sinapis  or  terebinthina  stupes 
over  the  chest,  or,  if  much  substernal  pain  and  sthenic,  a  few  dry  or 
even  wet  cups,  the  patient  being  confined  to  an  apartment  in  which 
the  air  is  moistened  by  the  vapor  of  hot  water. 

Second  Stage :  The  secretion  of  the  bronchial  mucous  membrane 
being  copious,  stimulating  expectorants  are  indicated,  such  as  ammonii 
chloridum,  scilla,  aintnonii  carbonas,  or  potassii  carbonas.  A  reliable 
combination  is : 

R,     Ammonii  chloridi, ^ij  8.  Gm. 

Scillse  aceti,     . f  3  iij  12.  Cc. 

Syr.  ipecac,    . f^ij  8-  Cc. 

Misturae  glycyrrhizse  comp.,  .      ad  f^iij  ad  90.  Cc. 
SiG. — Dessertspoonful  every  three  hours. 

Attacks  showing  a  tendency  to  linger  are  greatly  benefited  by  the 
following : 

B .     Terebeni, f  3  ij  8.     Cc. 

Creosoti, rr\^xxiv  1.5  Cc. 

Mucil.  acacise, q.  s.  q.  s. 

Aquae  chloroform!,      ....     adf^iij  ad  90.    Cc.  M. 

SiG. — One  teaspoonful  every  four  hours,  diluted. 

During  the  attack,  attention  must  be  given  to  the  secretions  and  to 
the  diet  of  the  patient.  During  convalescence  a  course  of  strychninae 
sulphas  or  tinctura  nucis  vomicae  is  valuable. 


CAPILLARY  BRONCHITIS. 

Synonyms.     Broncho-pneumonia  (?) ;  "  suffocative  catarrh." 
Definition.     An   acute   catarrhal   inflammation   of   the   mucous 
membrane  of  the  ier7ni}tal  bronchial  tubes,  or  bronchioles ;  charac- 
terized by  fever,  impeded  and  increased  respiration,  impeded  circula- 


294  PRACTICE    OF    MEDICINE. 

tion,  slight  cough  and  scanty  expectoration,  and  symptoms  of  non- 
aeration  of  the  blood. 

Causes.  Most  common  in  childhood,  following  exposure  to  cold 
or  sudden  changes  of  temperature  ;  occurs  also  in  the  aged,  and  also 
complicates  measles,  whooping  cough,  or  any  of  the  debilitating  dis- 
eases.    Tliere  may  be  a  special  germ. 

Pathological  Anatomy.  Ihperamia,  redness  and  swelling  of 
the  lining  membrane  of  the  bronchioles,  with  the  exudation  of  a 
tough,  tenacious  secretion. 

In  those  cases  in  which  the  air  cells  are  not  involved  the  air  passes, 
during  the  act  of  inspiration,  through  the  secretion  blocking  the 
smaller  tubes,  but  is  prevented  from  escaping  during  the  act  of 
expiration,  the  secretion  in  the  smaller  tubes  acting  as  a  valve  ;  the 
result  is  distention  of  numerous  vesicles,  producing  a  circumscribed 
or  diffused  functional  emphysema.  If  the  secretion  produces  com- 
plete closure  of  any  of  the  smaller  tubes,  the  air  previously  drawn 
into  the  vesicles  will  be  absorbed,  causing  pulmonary  collapse 
(atelectasis). 

If  the  inflammation  extends  to  the  alveoli  of  the  lungs,  it  produces 
the  condition  known  as  broncho-pneiimonia,  a  frequent  complication 
in  children  and  feeble  elderly  people  ;  it  is  most  commonly  lobular 
in  character,  whence  the  term  "  /obii/ar pneumonia."" 

Symptoms.  Usually  preceded  by  more  or  less  ordinary  bron- 
chitis, followed  by  rise  of  temperature,  102-103°  F.,  increased  pulse, 
difficult  z.T\di  increased  respiration,  numbering  forty,  fifty,  or  sixty  in 
the  minute,  with  paroxysms  in  which  the  dyspnoea  is  markedly  aggra- 
vated, when  cyanosis  rapidly  develops  ;  the  tongue  is  coated,  bowels 
costive,  appetite  impaired,  and  there  is  restlessness  and  headache. 

The  circulation  through  the  lungs  is  impeded  by  the  dyspnoea,  the 
/>«/y^  becomes  feeble  and  flickering,  and  there  results  general  con- 
gestion of  the  venous  system,  the  countenance  becomes  livid,  the  lips 
atid  nails  blue,  the  surface  cold,  and  often  covered  with  a  clammy 
perspiration,  the  mind  dull,  and  in  children  stupor  and  convulsions 
rapidly  supervene,  the  result  of  the  non-aeration  of  the  blood.  The 
cough  is  slight,  but  of  a  suppressed  character,  the  expectoration  scanty, 
the  patient  usually  swallowing  the  sputum.  When  cyanosis  occurs, 
the  cough  may  almost  entirely  cease ;  expectoration  also  ceases,  death 
soon  following  from  apncea  and  depression. 

Percussion.     Normal,  except  over  those  portions  of  the  lungs  (a 


DISEASES   OF  THE   BRONCHIAL  TUBES.  295 

bilateral  disease)  which  are  in  a  condition  of  collapse,  when  dullness 
rapidly  develops  and  may  as  rapidly  disappear,  changing  to  other 
portions  of  the  lungs — shifting  dullness. 

Auscultation.  First  stage,  a  feeble,  but  high-pitched,  respira- 
tory murmur,  becomes  less  distinct  and  harsh  as  the  disease  progresses. 
The  rales  in  the  first  stage  are  fine  whistling,  sibilant,  changing  in 
the  second  stage  to  fine  bubbling  or  subcrepitant  rales.  The  respira- 
tory murmur  is  absent  over  the  dull  area. 

Diagnosis.  There  is  one  point  characteristic  of  capillary  bron- 
chitis— it  is  a  general  or  bilateral  disease.  Capillary  bronchitis  is 
often  mistaken  for  true  catarrhal  pneumonia,  the  points  of  distinction 
between  which  will  be  pointed  out  when  discussing  the  latter  affection. 

Prognosis.  In  children,  on  account  of  their  inability  to  expec- 
torate, which  tends  to  rapid  collapse  of  the  lungs,  and  in  the  aged, 
the  prognosis  is  most  grave.  In  the  strong  and  vigorous,  recovery 
follows  prompt  and  energetic  treatment. 

Treatment.  From  the  very  onset  of  the  attack  the  treatment 
must  be  supporting,  with  the  addition  of  such  measures  as  seem  to 
possess  a  controlling  influence  over  the  catarrhal  process. 

The  patient  must  be  confined  to  bed,  well  covered,  and  the  tem- 
perature of  the  room  varying  between  75°  and  80°,  the  air  moistened 
with  steam,  or  adding  one  or  two  teaspoonfuls  of  tinctura  benzoin 
to  the  hot  water.  In  the  first  stage  dry  cups,  mild  smapis  applications, 
or  terebinthina  stupes  should  be  applied  to  the  chest,  after  which  it 
should  be  covered  with  an  oil-silk  jacket  or  a  cotton  jacket. 

The  diet  must  be  of  the  most  nutritious  character,  the  great  aim 
being  to  sustain  the  powers  of  life  until  the  catarrhal  process  has 
passed  through  the  different  stages  ;  hence  milk,  eggs,  chicken,  mut- 
ton and  beef  broths,  with  the  free  use  oi  stimulants,  commenced  early 
and  in  amounts  large  enough  to  overcome  the  signs  of  depression 
which  are  present  early  in  the  attack. 

Unless  the  fever  be  high,  102°  F.,  and  continues,  it  need  not  be 
treated,  but  if  it  continues  at  that  point  or  higher,  a  few  doses  of 
acetanilidum,  gr.  ij-iv  (o.  13-0.26 Gm.),  in  brandy  or  whiskey,  may  be 
used.     If  the  urine  be  scanty,  use  spiritus  astheris  nitrosi. 

If  suffocation  be  imminent,  the  cautious  use  oi  emetics  may  be  indi- 
cated ;  the  most  suitable  are  ipecacuanha  and  hydrargyri  subsulphas 
flavus,  or  the  hypodermic  use  of  apomorphina,  gr.  -^^  (0.003  Gm.). 
Do  not  repeat  emesis  often  enough  to  produce  exhaustion. 


296  PRACTICE   OF    MEDICINE. 

For  the  catarrhal  process  two  remedies  are  of  inestimable  value: 
one,  potassii  iodidum  or  amviotiii  todiduni,  gr.  j-ij  (0.065-0.13  Gm.) 
for  a  child  every  hour  or  two,  and  gr.  v-x  (0.3-0.6  Gm.)  for  an  adult, 
its  action  being  to  liquefy  or  thin  the  tenacious  secretion  and  modify 
the  inflammatory  action  ;  the  other  is  ainmonii  carbonas,  gr.  j-ij 
(0.065-0.13  Gm.)  for  a  child  every  hour  or  two,  and  gr.  v-x  (0.3-0.6 
Gm.)  for  an  adult.  The  two  combined,  but  for  the  taste,  make  a 
valuable  prescription : 

R.     Potassii  iodidi, gT'  'j  .13^111. 

Ammoiiii  carbonat. gr.  iij  .2    Gm. 

Syr.  glycyrrh., fo^s  2.       Cc. 

Syr.  tola, fSss  2.      Cc. 

SiG. — Every  two  or  three  hours. 

Excellent  results  have  been  obtained  in  the  children's  wards  of  the 
Philadelphia  Hospital  from  the  systematic  inhalation  of  oxygen. 
Prof.  H.  C.  Wood,  in  desperate  cases  of  suffocative  catarrh,  advises 
the  alternate  use  of  the  hot  and  cold  douche  conjointly  with  stimu- 
lating: remedies. 


FIBRINOUS  BRONCHITIS. 

Synonyms.  Membranous  bronchitis;  plastic  bronchitis;  diph- 
theritic bronchitis;  croupous  bronchitis. 

Definition.  An  acute  inflammation  of  the  mucous  membrane  of 
the  larger  and  middle-sized  bronchial  tubes,  attended  with  an  exuda- 
tion, forming  a  membraniform  layer,  which  is  closely  adherent  to  the 
mucous  surface  ;  characterized  by  febrile  reaction,  cough,  difficult 
breathing,  scanty  expectoration,  followed  by  the  expulsion  of  the 
false  membrane  in  the  form  of  patches  or  casts. 

Causes.  Unknown;  associated  with  membranous  laryngitis  from 
extension  downward;  asthma;  emphysema;  phthisis;  frequently 
result  of  exposure  to  cold  or  damp,  in  those  of  feeble  health  or  in 
tuberculous  (?)  constitutions. 

Pathological  Anatomy.  Hypercemia  of  the  mucous  mem- 
brane of  the  bronchial  tubes,  associated  with  sivc/Iing  nx\<\  oedema, 
during  which  the  surface  is  covered  with  a  whitish  or  grayish-white, 
firmly  adherent,  membranous  deposit,  cemented  together  by  a  coagu- 
lable  exudation,  and  prolonged  by  rootlets  from  its  under  surface  into 


DISEASES   OF  THE   BRONCHIAL   TUBES.  297 

the  bronchial  folHcles, which  sooner  or  later  is  loosened  and  detached 
by  suppurative  process,  and  is  expectorated  after  a  violent  fit  of 
coughing  or  vomiting.  When  expectorated,  Xhe  false  membrane,  as  it 
has  been  termed,  has  either  the  form  of  patches  or  is  thrown  off  en- 
tire from  the  bronchial  tube,  and  may  be  found  to  consist  of  casts 
representing  more  or  less  of  the  bronchial  subdivisions,  and  present- 
ing an  appearance  not  unlike  "  boiled  macaroni." 

On  7nicroscopical  examination,  the  detached  membrane  presents 
fibrillas  which  characterize  fibrin  or  lymph  in  other  situations  ;  and  if 
placed  in  a  solution  of  acetic  acid,  it  becomes  greatly  swollen,  while 
ordinary  mucus  contracts  and  becomes  more  dense  if  added  to  the 
same  solution. 

Symptoms.  There  are  no  symptoms  or  signs  by  means  of  which 
this  variety  of  bronchitis  can  be  distinguished  from  ordinary  catarrhal 
bronchitis,  prior  to  the  expectoration  of  the  false  m,embrane. 

Expectoration  is  preceded  and  accompanied  by  violent  paroxysms 
of  coughing,  and  after  more  or  less  of  the  membrane  has  been  raised, 
a  muco-purulent  expectoration,  streaked  with  blood,  may  be  present 
for  several  days. 

Duration.  The  inflammation  may  be  either  acute,  subactde,  or 
chronic,  expectoration  of  patches  or  strips  of  the  membrane  being 
repeated  at  intervals  of  days,  weeks,  months,  or  even  years. 

Prognosis.  In  adults,  favorable,  if  not  associated  with  other 
grave  affections,  such  as  phthisis,  pneumonia,  emphysema.  In 
young  children  it  may  cause  obstruction  to  the  respiration,  and  not 
infrequently  proves  fatal. 

Treatment.  As  the  character  of  the  inflammation  can  seldom 
be  determined  until  the  membrane  or  portions  of  it  have  been  expec- 
torated, the  treatment  is  at  first  the  same  as  in  attacks  of  ordinary 
acute  bronchitis. 

As  soon,  however,  as  the  character  of  the  inflammation  can  be  de- 
termined, active  emesis  is  the  most  effective  means  of  removing  the 
obstruction  caused  by  the  false  membrane,  the  best  agents  of  this 
class  being  eith^  hydrargyri  subsulphas  flavus,  apomorphina,  ipecac- 
uanha, or  zinci  sulphas,  to  be  repeated  as  indicated. 

Inhalations  of  solutions  of  ammonii  chloridum,  pix  liquida,  euca- 
lyptol,  or  simply  the  vapor  of  water,  and  especially  of  lime-water, 
are  highly  serviceable. 

To  prevent  the  formation  of  membrane,  Prof.  Bartholow  strongly 


298  PRACTICE    OF    MEDICINE. 

urges  the  use  of  ammonii  iodidutn  and  ammonii  carbonas  combined, 
in  small  doses,  every  hour  or  two.  In  a  case  treated  by  the  author 
after  this  method,  excellent  results  followed.  Potassii  iodidum  is  also 
useful. 

In  cases  showing  a  tendency  to  become  chronic,  good  results 
will  follow  the  application  of  flying  blisters  to  the  chest  and  the 
internal  administration  oi  arscniciim  and  some  preparation  oi  pix 
liquida. 

CHRONIC  BRONCHITIS. 

Synonyms.  Chronic  bronchial  catarrh  ;  winter  cough;  second- 
ary bronchitis. 

Definition.  A  chronic  inflammation  of  the  mucous  membrane  of 
the  larger  and  middle-sized  bronchial  tubes  ;  characterized  by  cough 
and  more  or  less  profuse  expectoration,  plus,  in  many  cases,  the 
symptoms  of  etnphysema  of  the  lungs,  which  is  a  frequent  complica- 
tion. 

Chronic  bronchitis  may  be  €\\\\tx  primary  or  secondary. 

Causes.  Primary,  exposure  to  wet  or  cold,  or  the  repeated  inha- 
lation of  dust,  vapors,  or  other  irritants.  Secondary,  gout,  rheuma- 
tism, syphilis  ;  cardiac,  renal,  or  pulmonary  diseases,  or  alcoholism. 

Varieties.  I.  Mucous  catarrh,  associated  with  moderate  expec- 
toration. II.  5r<7«r//<7rr^a?a,  profuse  expectoration.  \\\.  Diy  catarrh, 
scanty  expectoration.  IV.  Fetid  bronchitis.  V.  Bronchiectasis,  or 
dilatation  of  the  bronchi. 

Pathological  Anatomy.  The  mucous  membrane  of  the  bron- 
chial tube  is  discolored,  being  of  a  more  or  less  dull  red,  often  of  a 
deeply  venous  hue,  mingled  with  a  grayish  or  brownish  color.  These 
changes  may  be  either  in  patches  or  extensively  diffused.  The  ves- 
sels of  the  mucous  membrane  are  dilated.  The  mucous  membrane 
is  thickened,  resulting  in  reduction  in  the  calibre  of  the  tube  and 
a  roughening  of  its  internal  surface.  The  submucous  tissue  becomes 
infiltrated,  contracted,  and  indurated.  * 

The  elastic  and  muscular  coats  of  the  tubes  become  hypertrophied, 
lose  their  elasticity,  and  the  cartilages  become  the  seat  of  calcareous 
deposits. 

As  the  result  of  the  loss  of  elasticity  and  muscular  tone  of  the  tubes 
they  become  irregularly  dilated — "  bronchial  dilatation."  The  dilata- 


DISEASES   OF  THE   BRONCHIAL  TUBES.  299 

tions  may  be  uniform  in  character,  resembling  somewhat  the  fingers 
of  a  glove,  or  they  may  be  sacculated  or  globular,  forming  actual 
cavities  in  the  bronchial  structure. 

In  the  mucous  variety  the  secretion  consists  of  young  cells  and 
mucous  corpuscles,  having  a  yellowish  color  ;  in  the  dry  variety,  the 
"catarrhe  sec"  of  Laennec,  or  "dry  bronchial  irritation,"  the  secre- 
tion is  scanty,  tough,  semi-transparent,  and  occurs  in  globular 
masses  ;  in  bronchorrhaea,  which  is  usually  associated  with  bronchial 
dilatation,  the  secretion  is  abundant,  greenish-yellow  in  color,  and 
frequently  fetid. 

The  majority  of  cases  of  chronic  bronchitis  are  associated  with 
chronic  gastric  catarrh. 

Symptoms.  The  most  characteristic  symptoms  of  chronic  bron- 
chitis are  the  cough  and  expectoration.  The  cough  occurs  at  all  hours, 
but  is  more  severe  at  night  and  early  in  the  morning.  The  cough  is 
not  always  present.  It  disappears  almost  altogether  for  a  time,  and 
then  reappears,  continuing  thus  for  years.  Coated  tongue,  disagree- 
able taste,  loss  of  appetite,  impaired  digestion,  with  eructations  of 
gases,  are  present  in  many  cases,  due  to  the  chronic  gastric  catarrh. 
Unless  associated  with  other  diseases,  the  general  health  suffers  but 
little,  if  at  all,  constitutional  symptoms  being  present  only  during 
acute  exacerbations. 

Mucous  catarrh,  or,  from  its  occurring  most  commonly  during  the 
winter  months,  "winter  cough,"  is  characterized  by  paroxysms  of 
cough,  more  or  less  violent,  followed  by  the  expectoration  of  a  yellow- 
ish mucus. 

Dry  catarrh  is  characterized  by  a  harsh  cough,  a  feeling  of  soreness 
or  rawness  under  the  sternum,  and  the  expectoration  of  small  globu- 
lar jnasses  ;  this  variety  occurs  with  emphysema,  gout,  rheumatism, 
and  asthma. 

Bronchorrhcaa,  which  is  associated  with  bronchial  dilatation,  and 
most  common  in  the  elderly,  is  characterized  by  paroxysms  of  severe 
coughing,  followed  by  the  copious  expectoration  of  greenish-yellow, 
often  fetid,  mucus ;  the  amount  expectorated  often  amounts  to  four 
or  five  pints  in  the  twenty-four  hours. 

Fetid  bronchitis,  often  associated  with  bronchial  dilatation,  has  an 
excessively  fetid  odor  of  the  breath  and  expectoration.  The  decom- 
position of  the  secretion  may  cause  gangrene  of  the  bronchial  mucous 
membrane,  and  even  of  the  lung  structure. 


300  PRACTICE    OF    MEDICINE. 

Percussion.  Unless  complicated  with  other  affections,  normal ; 
if  bronchial  dilatation  occur,  there  are  diffused  spots  of  the  tympanitic 
or  amphoric  percussion  sound,  the  physical  condition  being  a  circum- 
scribed cavity  containing  air  and  communicating  with  a  bronchial 
tube. 

Auscultation.  Harsh  or  vesiciilo-bronchial  respiration,  asso- 
ciated with  more  or  less  profuse,  sonorous,  sibilant,  and  large  and 
small  bubbling  rales  ;  in  bronchial  dilatation,  in  addition  to  the  harsh 
respiration,  is  found  broncho-cavernous  breathing,  with  large  and 
small  gurgling  rales. 

If  emphysema  complicate  chronic  bronchitis,  the  physical  signs  are 
somewhat  modified,  and  will  be  pointed  out  when  discussing  that 
affection. 

Diag'nosis.  Always  examine  the  urine  in  case  of  cough,  and 
particularly  in  chronic  bronchitis,  as  this  disease  is  one  of  the  most 
frequent  complications  of  Bright's  disease. 

Incipient  phthisis  is  often  confounded  with  chronic  bronchitis.  The 
diagnosis  is  not  always  easy.  The  physical  signs  of  chronic  bron- 
chitis are  more  or  less  diffused  through  both  lungs,  and  not,  as  a  rule, 
associated  with  failure  of  the  general  health  ;  while  in  phthisis,  from 
the  onset,  there  is  failing  health,  with  a  concentration  of  the  physical 
signs  to  the  apices.  The  discovery  of  the  bacillus  determines  the 
diagnosis. 

Prognosis.  If  unassociated  with  disease  of  the  lungs,  heart,  or 
kidneys,  chronic  bronchitis  is  never  dangerous  to  life,  although  the 
symptoms  are  present,  more  or  less,  contmually,  and  aggravated 
upon  the  least  exposure.     Rarely  is  a  complete  cure  recorded. 

If  associated  with  phthisis,  emphysema,  diseases  of  the  heart  or  of 
the  kidneys,  the  prognosis  is  governed  by  these  affections.  In  turn, 
it  is  to  be  remembered  that  chronic  bronchial  catarrh  may  lead  to 
emphysema  of  the  lungs,  asthma,  or  to  cardiac  dilatation. 

Treatment.  Cases  of  chronic  bronchitis,  of  whatever  variety, 
should  observe  the  following  general  rules:  i.  Attention  to  the  gen- 
eral health.  2.  The  clothing;  wearing  flannel  the  year  round,  or, 
what  is  better,  silk  underclothing,  avoiding  the  opposite  extreme 
of  excessive  clothing. 

The  medical treatmentis  guided  by  the  cause,  character,  and  severity 
of  the  disease. 

If  secondary  to  other  affections,  in  the  majority  of  cases  remedies 


DISEASES   OF  THE   BRONCHIAL  TUBES.  301 

directed  to  the  bronchial  mucous  membrane  are  contra-indicated. 
If  the  result  of  the  rheumatic  or  gouty  diathesis,  in  addition  to  the 
remedies  directed  to  the  disease  itself,  should  be  combined  change 
to  a  warm  climate,  if  possible,  and  a  more  or  less  protracted  course 
o^  fiotassii  iodidu7n,  or  lithii  citras,  or  a  residence  at  one  of  the  alka- 
line sprijtgs. 

If  associated  with  alcoholism  or  chronic  gastric  catarrh,  the  follow- 
ing is  a  valuable  combination  : 

R.     Ammonii  chloridi,      J^iij  12.  Gm. 

Tinct.  nucis  vomicse, f^ij  8.  Cc. 

Infus.  gentianse  comp.,  .    q.  s.  adf^iv  ad  I20.  Cc.  M. 

SiG. — Dessertspoonful  in  water  before  meals. 

For  mucous  catarrh  with  acute  exacerbations  : 

R.     Ammonii  chloridi, ^\]  8.         Gm. 

Glycerin!, f^iss  45.         Cc. 

Codeinge  sulph., gr.  j  .065  Gm. 

Vini  picis  liq., f.^i'j  9°-         Cc. 

Syr.  prun.  virg., f^iss  45.         Cc.  M. 

SiG. — Tablespoonful  every  three  or  four  hours. 

Dry  catarrh  is  greatly  benefited  by — 

R.     Potassii  iodidi, gr.  v-x  .3-.6  Gm. 

Elix.  cinchonse, Ti\^xx  1. 3        Cc. 

Vini  picis  liq., adf^ss  ad   15.  Cc.  M. 

Three  times  a  day. 

For  an  acute  exacerbation  of  dry  or  tenacious  chronic  bronchitis : 

R.     Ammonii  chloridi, giv  15.  Gm. 

Tinct.  hyoscyam., f^i"^  ^S-  Co. 

Syr.  scillse  comp., f.^iv  iS-  Cc. 

Aq.  chloroformi, f^ij  60.  Cc.  M. 

SiG. — One  teaspoonful  every  three  hours,  diluted. 

An  excellent  expectorant  combination  in  all  forms  and  at  any  stage 
of  bronchial  catarrh  is  : 

R.      Ammonii  carbonat. , gr.  xvj  I.  Gm. 

Ext.  scillse  fld., f.^ss  2.  Cc. 

Ext.  senegas  fld., f^ss  2.  Cc. 

Tinct.  opii  camphorat.,      ....  f.^iij  12.  Cc. 

Syr.  tola, f^iss  45-  Cc.  M. 

SiG. — Teaspoonful  every  few  hours,  diluted. 


302  rRACTICC    OF    MKOICINE. 

For  brotic/iorr/iaa,  copaiba,  n\^v-x  (0.3-0.6  Cc),  every  three  hours, 
or  sp/s.  terebintliince,  Ti\,v  (0.3  Cc),  every  four  hours,  or  acidum  car- 
bolicitm,  gr.  ss  (0.032  Gm.),  four  times  a  day,  are  excellent  drujjs,  or — 


R .     Tereheni, f  J5  ij  8.  Cc, 

Creosoii,      " 

Acacire, 


Aq.  cliloroformi, 
Syr.  prun.  virg. , 


ITLxxx  2.  Cc. 

q   s.  q.  s. 

f.^j  30-  Cc. 


ad  f.^iij  ad  90.  Cc.  M. 


SiG. — Teaspoonful  every  three  or  four  hours,  diluted. 

And  at  the  same  time  using  ol.  tnorrhuce  and  arsenicum,  or,  if  these 
means  fail,  inhalations  of  alumen,  acidum  gallicum,  or  acidum  tan- 
nicutn. 

If  the  expectoration  be  fetid,  "  ffetid  bronchitis,"  Prof.  Da  Costa 
recommends  the  internal  use  of  acidum  carbo/icum,  n\,j  (0.06  Cc), 
every  third  hour,  vifith  inhalations  of  acidum  carbolicum,  gr.  v  (0.32 
Gm.),  aqttcB,  f5J  (30  Cc),  two  or  three  times  a  day.  Good  results 
may  also  be  obtained  from  the  terebene  and  creosote  mixture  given 
above. 

If,  after  prolonged  treatment,  cure  or  great  amelioration  does  not 
occur,  then  a  change  of  climate  is  called  for.  Usually  a  warm  climate 
is  the  most  suitable,  but  sometimes  a  dry,  bracing  climate  does 
better. 

Locally,  irritation  with  tinctura  iodi,  or  flying  blisters,  repeated  once 
or  twice  weekly,  is  of  advantage. 


ASTHMA. 

Synonyms.  Bronchial  asthma  ;  spasmodic  asthma. 
Definition.  A  paroxysmal,  spasmodic  contraction  of  the  mus- 
cular layer  surrounding  the  smaller  bronchial  tubes,  and  perhaps 
associated  with  a  tonic  spasm  of  the  diaphragm  and  more  or  less 
bronchial  catarrh  ;  characterized  by  spasmodic  attacks  of  distressing 
expiratory  dyspnoea,  continuing  several  hours,  days,  or  weeks. 

Cause.  A  true  neurosis  of  the  respiratory  apparatus.  The  result 
of  peripheral  or  local  disturbances  in  the  nervous  system.  Chiefly 
hereditary.  A  family  history  of  asthma,  chorea,  or  epilepsy.  It 
is  sometimes  of  reflex  origin,  starting  from  diseases  of  the  nasal 
mucous  membrane,  explaining  the  attacks  due  to  the  inhalation  of 


DISEASES   OF  THE  BRONCHIAL  TUBES.  303 

various  substances,  as  ipecac,  turpentine,  or  irritating  dusts.  Climate. 
Some  attacks  may  be  due  to  a  peculiar  and  characteristic  disease  of 
the  bronchial  mucous  membrane  —  an  "asthmatic  bronchiolitis." 
Bronchitis;  "peri-bronchitis";  emphysema;  chronic  cardiac  disease; 
chronic  gastric  catarrh ;  malarial  toxaemia. 

Asthma  is  more  common  in  men  than  in  women,  and  may  occur  at 
any  age. 

Pathological  Anatomy.  Unless  a  "  peri-bronchitis,"  nothing 
purely  distinctive.     The  changes  of  emphysema  are  common. 

Symptoms.  The  onset  of  3.  first  attack  of  asthma  is  abrupt  and 
sudden,  the  succeeding  attacks  being  preceded  hy  prodrotfies,  which 
the  individual  rapidly  learns  to  appreciate — to  wit :  coryza,  bronchial 
irritation,  thoracic  cons  trie  tioti,  marked  dyspepsia,  or  the  scanty  pas- 
sage of  pale,  limpid  urine,  the  "  hysterical  urine." 

The  paroxysm  begins,  in  the  majority  of  instances,  in  the  earty 
morning  hours  or  during  the  afternoon,  with  a  feeling  of  anguish 
and  constriction  in  the  chest  and  an  intejise  desire  for  air.  The 
breathing  is  accompanied  with  loud  wheezing,  the  face  is  flushed,  at 
times  even  cyanosed  and  bathed  in  perspiration,  the  eyes  staring,  the 
eyeballs  protrude,  and  the  muscles  of  the  neck  become  prominent  as 
they  aid  in  the  effort  for  air.  The  dyspncea  soon  becomes  so  severe 
that  the  inspiration  is  but  a  gasp,  the  lips  are  pallid,  cyanosis  deepens, 
and  the  patient  feels  as  if  death  were  impending.  Owing  to  the 
tonic  contraction  of  the  smaller  bronchi,  the  air  drawn  into  the  alveoli 
escapes  imperfectly,  resulting  in  the  expiratory  dyspnoea,  the  emphy- 
sematous chest,  and  the  lowered  position  of  the  diaphragm. 

After  some  minutes  or  hours  the  respiration  becomes  easier,  the 
air  in  the  lungs  changes,  the  cyanosis  disappears,  and  gradually  the 
paroxysm  ceases,  the  patient  feeling  exhausted  and  the  chest  fatigued. 

During  the  paroxysm  there  is  a  short,  dry  cough,  becoming  looser 
as  the  attack  subsides.  The  sputum  of  asthma  is  unique.  Early  in 
the  paroxysm  it  is  raised  with  difficulty,  and  is  in  the  form  of  rounded 
gelatinous  masses  ("pedes"  of  Laennec).  If  these  pellets  be  care- 
fully examined,  they  will  be  found  to  consist  of  moulds  of  the  smaller 
bronchi,  and,  under  the  microscope,  show  Leyden's  crystals  and 
Curschmann's  spirals.  After  a  day  or  two  the  sputum  becomes 
muco  purulent,  and  the  spirals  and  crystals  are  absent. 

The  duration  of  an  attack  varies  from  one  to  many  hours,  or  even 
days.     Instead  of  single  paroxysms,  slight  remissions  may  occur  at 


304  PKACTICE    OF    MKDICINE. 

intervals  of  one,  two,  or  three  hours,  to  be  followed  by  exacerbations 
lasting  from  four  to  six  hours,  continuing  for  a  week  or  two,  prevent- 
ing the  patient  lying  down  or  taking  food. 

Percussion.  During  the  paroxysm,  hyper  resonance  over  both 
lungs,  termed  vcsiculo-iympanitic,  the  "band-box  tone"  of  Bam- 
berger, due  to  the  retained  air  in  the  alveoli. 

Auscultation.  First  stage  feeble  or  absent  vesicular  murmur, 
with  prolonged  expiration  associated  with  loud  wJieezing,  whistling, 
sibilant  and  sonorous  rales ;  as  the  paroxysm  subsides,  the  vesicular 
breathing  becomes  more  apparent  and  is  associated  with  moist  rales. 

Prognosis.  In  itself  asthma  is  not  fatal  to  life  ;  but  if  the  parox- 
ysms are  frequently  repeated,  there  results  either  emphysema,  cardiac 
dilatation  with  subsequent  dropsy,  or  even  cerebral  hemorrhage. 

Attacks  of  asthma  frequently  occur  as  a  complication  in  emphy- 
sema, chronic  bronchitis,  valvular  diseases  of  the  heart,  and  Bright's 
disease. 

Treatment.  There  are  two  indications  to  meet:  the  relief  of  the 
paroxysm,  and  to  prevent  its  recurrence. 

To  relieve  the  paroxysm,  no  medication  is  so  effective  as  the  hypo- 
dermic injection  of  viorphince  sulphas,  gr.  y(,-%  (0.011-0.016  Gm.), 
combined  with  atropines  sulphas,  gr.  ^J^  (0.00065  Gm.).  Chloral,  gr.  x 
(0.6  Gm.),  repeated,  where  no  heart  complication  exists,  is  often 
effective.  Drinking  strong,  hot,  black  coffee  is  often  serviceable. 
Caffeine  citrata  during  or  at  the  onset  of  a  paroxysm,  in  doses  of  gr. 
iij-v  (0.2-0.3  Gm.),  hypodermically,  or  in  a  cachet  or  in  solution,  re- 
peated until  bronchial  spasm  is  relieved,  is  a  valuable  drug.  Page 
strongly  recommends  sodii  nitras  : 

li.      Pulv.  sodii  nitritis, gr.  xxiv  1.6  Gm. 

Aquae, f3J  30.     Cc.  M. 

SiG. — Teaspoonful  at  once  ;  repeat  in  half  an  hour,  once  or  twice  if  necessary. 

The  following  combination  by  hypodermic  injection  is  often  most 
successful  in  relieving  an  attack  of  asthma,  and  particularly  if  compli- 
cated with  cardiac  or  nephritic  disease,  continuing  the  combination 
after  relief,  in  pill  form  or  solution  at  ordinary  intervals  for  several 
days: 

R.     Spirit,  glonoini,       TTLij  .12      Cc. 

Strychnine  sulph., S""-  3V  -OO^S  Gm. 

Morphince  sulph., g''-  ^V  •°°3    *^™"      ^' 

SiG. —  Dose. 


DISEASES   OF  THE   BRONCHIAL  TUBES,  305 

Chloroformii7n,  cether,  or  amyl  nitris  inhalations  have  been  recom- 
mended, and  also  the  naiiseant  expectorants,  lobelia,  ipecac,  and 
scilla.  Ext.  grindelicE  fld.,  TTLxx  (1.3  Cc),  repeated  every  two  or 
three  hours  is  sometimes  useful. 

Dr.  Pepper  speaks  highly  of  the  following  for  the  paroxysm  : 

B  .     Ammonii  bromidi, '    5  'J  9  'J  i°-  Gm. 

Ammonii  chloridi, 3  iss  6.  Gm. 

Tinct.  lobeliae, f^iij  ^2.  Cc. 

Spts.  Eetheris  comp., f^^j  30.   Cc. 

Syr.  acacia, q.s.  f^iv  ad  120.  Cc.  M. 

SiG. — Dessertspoonful  in  water  every  hour  or  two,  diluted. 

After  the  use  of  many  drugs  I  have  finally  come  to  depend  upon 
potassii  iodidum,  gr.v-x  (0.3-0.6  Gm.),  every  three  hours,  either  alone 
or  combined  with  tinctura  belladonncz,  n\,v  (0.3  Cc),  or  nitro- 
glycerin,  gr.  ^o~t^  (0.00032-0.00065  Gm.),  to  remove  the  catarrhal 
condition  remaining  after  a  paroxysm  and  to  prevent  a  return. 

Another  remedy  that  at  times  is  successful  is  sympus  acidi  hydrio- 
dici,  f3ss-f5  (2-4  Cc),  every  three  or  four  hours,  well  diluted. 

Inhalations  of  the  fumes  of  belladonna,  stramoniutn,  nitre-paper, 
chloroform,  ethyl  brofttidum,  or  the  use  of  various  pastilles  or  cigar- 
ettes, are  of  immense  benefit  in  many  cases,  A  twenty  per  cent,  solu- 
tion of  menthol  as  an  inhalation  has  been  successful  in  some  instances. 
Inhalations  of  oxygen  have  given  excellent  results  in  a  number  of 
cases. 

If  an  attack  is  impending,  it  may  often  be  aborted  by  drinking  freely 
of  strong,  black  coffee,  or  by  full  doses  of  the  bromides. 

To  prevejit  the  recurrence  of  the  paroxysms,  the  general  health 
must  be  cared  for,  and  any  suspected  causes  corrected.  In  all  cases 
a  thorough  examination  of  the  nasal  mucous  membrane  should  be 
made  and  any  diseased  condition  found  removed.  If  chronic  bron- 
chitis be  present,  it  should  be  persistently  treated. 

Two  remedies  long  continued  frequently  give  good  results :  potassii 
iodidum  in  doses  ranging  from  five  to  fifteen  grains  (0.3-1  Gm.),  and 
arsefiicum  in  small  doses. 

Additional  aids  are  systematic  exercise  short  of  fatigue,  bathing, 
regulated  diet,  and,  when  possible,  a  change  of  climate. 


20 


306  PRACTICE    OF    MEDICINE. 


HAY  ASTHMA. 

Synonyms.  Hay  fever ;  autumnal  catarrh  ;  rose  fever ;  rose 
cold. 

Definition.  An  acute,  specific,  catarrhal  inflammation  of  the 
upper  air  passages,  extending  to  the  bronchial  tubes,  associated  with 
spasmodic  contraction  of  their  muscular  layer,  occurring  at  a  par- 
ticular season  of  the  year,  characterized  by  coryza,  croupy  or  wheezy 
cough,  and  difficult  respiration. 

Causes.  A  predisposition,  often  hereditary,  of  the  nervous  system 
seems  to  be  a  strong  etiological  factor. 

Persons  in  whom  the  predisposition  exists  have  attacks  excited  by 
the  inhalation  of  the  pollen  of  grasses,  rye,  corn,  wheat,  or  roses. 

Pathological  Anatomy.  Hypertrophy  of  the  inferior  and 
middle  turbinated  bones;  a  peculiar  hyperesthesia  of  the  mucous 
membrane  covering  the  inferior  and  middle  turbinated  bones,  the 
middle  meatus,  the  floor  of  the  nose,  and  that  part  of  the  septum 
below  the  limit  of  the  olfactory  membrane  are  frequently  associated 
with  the  disease. 

Symptoms.  Begins  by  irritation  of  the  eyes,  severe  coryza,  with 
sneezijig ;  a  clear,  watery,  nasal  discharge,  and  congested  Eustachian 
tubes,  rapidly  extending  to  the  larynx  and  bronchial  tubes,  when 
occurs  a  hoarse,  croupy,  and  wheezing  cough,  and  difficulty  of  breath- 
ing. The  dyspnoea  occurs  in  paroxysms,  which  are  often  as  severe 
as  those  occurring  during  a  regular  asthmatic  attack.  There  is  mild 
depression  of  the  nervous  system  in  nearly  all  attacks. 

The  paroxysms  remit  after  a  few  days,  returning  again  for  several 
days  or  weeks,  and  again  remitting,  the  bronchial  catarrh  persisting 
for  a  month  or  more. 

The  constitutional  symptoms  are  mild,  unless  complications  occur. 

Complications.  The  affection  may  extend  to  the  finer  bronchial 
tubes  (capillary  bronchitis);  congestion  or  oedema  of  the  lungs  and 
pneumonia  are  not  infrequent. 

Duration.  Unless  a  change  of  climate  is  resorted  to,  paroxysms 
of  hay  fever  continue  more  or  less  severe  for  six,  eight,  or  ten  weeks 
of  the  year,  each  year  the  paroxysms  growing  more  severe. 

Prognosis.  The  affection  never  proves  fatal  in  itself,  but  one 
or  more    of  the   following   sequelae    may   result,   to   wit :    asthma, 


DISEASES   OF  THE   BRONCHIAL  TUBES.  307 

chronic  bronchitis,  or  loss  of  the  special  sense  of  hearing  or  of 
smelling. 

Treatment.  No  specific,  unless  the  hypertrophy  of  the  turbin- 
ated bones  be  a  constant  condition,  when  their  removal  by  the 
galvano-cautery  would  remove  the  liability  to  attacks. 

An  attack  of  hay  asthma  is  often  prevented  by  a  change  of  climate 
during  the  season  of  the  year  when  the  attacks  are  most  common,  to 
wit:  the  early  autumn.  Any  of  the  following  locations  may  be 
selected — White  Mountains,  Catskills,  Adirondacks,  Rocky  Moun- 
tains, or  a  sea  voyage. 

Dr.  W.  C.  HoUopeter  reports  wonderful  success  in  over  two  hun- 
dred patients  with  the  following  plan  of  treatment : 

"For  the  last  ten  years  I  have  used  the  ordinary  Dobell's  solution.  This 
I  thoroughly  use  in  both  nostrils,  first  by  means  of  a  hand-ball  atomizer,  after 
which,  with  a  curved  aluminum  applicator,  I  very  carefully  swab  the  whole 
naso-pharynx.  I  scrub  most  carefully  every  portion  of  the  mucous  membrane, 
being  sure  to  reach  between  the  turbinated  bones  and  all  around  and  over 
every  slight  prominence.  I  then  as  carefully  dry  the  membrane  with  clean 
cotton,  and  use  freely  blandine  comp.  (a  mild  solution  of  menthol  in  albolene), 
loosely  plugging  the  nose  for  a  few  minutes  to  retain  the  oily  application. 
Great  stress  is  laid  upon  the  thoroughness  of  the  application  and  the  correction 
of  any  ills  the  patient  may  have." 

Attacks  are  sometimes  aborted  and  always  relieved  by  the  applica- 
tion to  the  nares  of  tablets  of  cocaincB  hydrochloras,  gr.  ^  (o.oi  i  Gm.), 
or  a  four  or  six  per  .centum  solution,  every  few  hours.  On  several 
occasions  pulvis  ipecacuanhce  et  opii,  gr.  v  (0.3  Gm.),  ter  die,  has 
aborted  a  suspected  attack,  as  has  the  following  pill : 

B .     Atropinse  sulph., gr-  i  -012  Gm. 

Morphinse  sulph., gr.  \  .016  Gm. 

Strychninse  sulph., gr.  |-  .008  Cm. 

Quininee  muriat., gr.  x  .65     Gm. 

Sodii  arseniat., g^-  i  -Oll  Gm.         M. 

Ft.  pil.  No.  XXX. 

SiG — One  every  hour  until  dryness,  then  two  or  three  hours  apart. 

Success  has  followed  the  use  of  qui^tince  sulphas,  gr.  v  (0.3  Gm.), 
three  times  a  day,  beginning  one  month  before  the  expected 
paroxysm. 

Bartholow  "  has  seen  several  cases  benefited  greatly  "  by  a  solution 
of  guinina  applied  to  the  nares,  as  suggested  by  Helmholtz,  "but  to 
achieve  success  the  application  must  be  thorough  and  timely." 


3U8  PRACTICE   OF    MEDICINE. 

The  following  applied  ihoroui^lily  to  the  nostrils  has  a  high  re])ule ; 

li.     Menthol,      ^j  4.  Gm. 

Ccrat.  siinpl.,      s  ij  60.  Gm. 

01.  amyL,'(l.  diilcis, f.^'ss  45.  Cc. 

Zincioxidi  punv, gj  4.  Gm. 

Acid,  carbolici, gss  2.  Gm. 

SiG. — Apply  every  two  hours. 

A  long  course  of  arsenicum  in  minute  doses  sometimes  removes 
the  susceptibility  to  the  disease. 


WHOOPING  COUGH. 

Synonyras.     Hooping  cough  ;  pertussis. 

Definition.  A  convulsive,  paroxysmal  cough,  consisting  of  a 
number  of  forcible  expirations,  followed  by  a  series  of  deep,  loud, 
sonorous  inspirations  (the  whoop),  repeated  several  times  during  each 
paroxysm,  and  associated  with  catarrh  of  the  bronchial  tubes. 

Causes.  Chiefly  a  disease  of  childhood,  and  fully  one-half  of 
the  cases  are  during  the  first  two  years  of  life,  one  attack  generally 
removing  the  susceptibility ;  contagious;  due  to  an  unknown  micro- 
organism. 

Pathology.  The  changes,  if  any,  occurring  in  the  nervous  sys- 
tem are  unknown.  It  is  said  that  "  irritation  of  the  internal  branch 
of  the  superior  laryngeal  nerve  produces  relaxation  of  the  diaphragm, 
spasm  of  the  glottis,  and  a  convulsive  expiration,  the  series  of  phe- 
nomena present  in  a  paroxysm  of  asthma." 

HypercBtnia  of  the  mucouS  membrane  of  the  nares,  pharynx,  larynx, 
and  bronchial  tubes,  with  diminished  secretion,  followed  by  an  in- 
creased secretion  of  a  transparent  mucus,  afterward  becoming  puru- 
lent, the  mucous  membrane  pale  and  anaemic. 

Symptoms.  Divided  into  three  stages,  to  wit :  catarrhal,  spas- 
modic, and  tenninal. 

Catarrhal  stage  originates  in  an  ordinary  naso-laryngo-bronchial 
catarrh,  with  a  loose  cough.     Duration,  one  or  two  weeks. 

Spasmodic  Stage  :  The  cough  becomes  paroxysmal,  consisting  of 
a  succession  oi  short,  rapid,  expiratory  efforts,  the  face  becoming  red, 
the  eyes  swollen  and  protruding,  the  body  bending  forward,  and  when 
these  expiratory  efforts  have  exhausted  the  breath,  they  are  followed 


DISEASES   OF  THE   BRONCHIAL  TUBES.  309 

by  a  deep,  loud,  crowtftg  inspiration — the  ivhoop  :  each  paroxysm 
being  composed  of  three  such  spells,  the  last  one  followed  by  the 
expectoration  of  a  small  amount  of  tough,  viscid  mucus. 

The  attacks  of  cough  may  be  so  severe  as  to  cause  vomiting,  and 
if  the  vomiting  occur  shortly  after  food  has  been  taken,  the  nutrition 
of  the  patient  will  suffer.  Profuse  epistaxis  is  not  infrequent.  Dura- 
tion, about  four  weeks. 

Terminal  Stage  :  The  paroxysms  recur  at  longer  intervals,  are  of 
shorter  duration  and  less  intensity,  the  catarrhal  symptoms  being 
more  marked,  the  expectoration  freer.  Duration,  one  or  two  weeks, 
often  followed  by  the  "  cough  of  habit." 

Coraplications.  Congestion  of  the  lungs,  capillary  bronchitis, 
pneumonia,  and  emphysema,  or,  rarely,  convulsions,  hydrocephalus, 
or  apoplexy. 

Diag'nosis.  During  the  catarrhal  stage  whooping  cough  cannot 
be  distinguished  from  a  common  cold,  but  on  the  advent  of  the  char- 
acteristic whoop,  the  diagnosis  is  determined. 

Prognosis.  Depends  upon  the  age  and  strength  of  the  patient, 
the  severity  of  the  paroxysms,  and  the  presence  or  absence  of  com- 
plications. Ordinary  cases,  favorable.  Moderately  severe  attacks 
during  infancy  are  followed  by  cerebral  symptoms,  while  attacks 
occurring  in  adults  are  followed  by  chest  symptoms. 

Treatment.  No  specific.  A  self-limited  disease.  Remedies  will 
not  cure  the  disease,  but  often  lessen  the  duration  of  or  modify  the 
severity  of  the  symptoms.     Always  watch  the  heart's  action. 

Prof.  Da  Costa  prefers  quinincB  sulphas  in  full  doses,  or  chloral  \n 
good-sized  doses,  often  advantageously  combined  with  the  bromides, 
and  the  use  of  a  spray  oi  sodii  bromidum,  gr.  xx  (1.3  Gm.),  and  aquse, 
f^j  (30  Cc),  to  which  may  be  added  extractum  belladonncB  fluidiim, 
TTLij  (0.12  Cc).  A  remedy  of  great  utility  is  ammonii  bromidum.. 
Excellent  results  have  followed  the  use  of  antipyrin  gr.  ^-v  (o.oii- 
0.3  Gm.),  or  acetanilidtim,  gr.  j-iij  (0.065-0.2  Gm.),  every  four  hours, 
according  to  the  age,  ox  phenacetin,  gr.  j-ij  (0.065-0.13  Gm.),  four 
times  daily.  Either  of  these  drugs  seems  to  act  better  if  given  with 
an  expectorant.  L.  Emmett  Holt  recommends  atitipyrin,  gr.  j  (0.065 
Gm.),  every  three  hours  for  child  six  months  old.  Terpini  hydras, 
gr.  j-ij-v  (0.065-0.13-0.3  Gm.),  is  sometimes  valuable.  Belladonna 
may  be  added  to  any  of  the  remedies  named  with  advantage,  or 
the  tincture  may  be  used  alone  in  doses  of  Tr\,v-x  (0.3-0.6  Cc.)  three 


310  PRACTICE    OF    MEDICINE. 

times  daily  until  flushing  of  the  surface,  and  a  dose  continued  that 
maintains  the  flushing. 

Starr  recommends  the  following  for  a  child  of  one  year: 

li .     Ext.  belladonna:, gr.  j  .065  Gm. 

Aluminis, 3  ss  2.         Gm. 

Syr.  zingiberis, 
Syr.  acacii^, 

Aquce, ^^o)  *^        3°-        ^^'  ^^• 

SiG. — A  teaspoonful  four  times  in  tlie  twenty-four  hours. 

Inhalations  of  creosote  are  very  valuable,  dropped  upon  cotton  in 
a  respirator,  or  vaporized  over  an  alcoholic  lamp,  or  cloths  dipped 
in  solutions  may  be  hung  in  the  room.  Eucalypiol'x's,  also  a  valuable 
remedy  for  inhalation. 

The  diet  of  the  patient  must  be  regulated,  the  clothing  to  be  warm 
but  not  too  heavy,  and  the  patient  kept  in  the  open  air  as  long  as 
possible. 

EMPHYSEMA. 

Synonym.    Vesicular  emphysema. 

Definition.  Dilatation  of  or  increase  in  the  size  and  capacity  of 
the  air  vesicles,  characterized  by  enlargement  or  distention  of  the 
lungs,  difficulty  of  breathing,  especially  on  exertion,  and  associated 
sooner  or  later  with  dilatation  of  the  heart. 

Causes.  The  predisposing  cause  of  emphysema  is  a  hereditary 
nutritive  derangement  of  the  lung  structure,  often  associated  with  a 
rigid  enlargement  of  the  thorax. 

The  exciting  cause  is  the  result  either  of  a  too  forcible  and  long 
continued  inspiration, — the  theory  of  inspiration, — or  the  excessive 
mechanical  distention  of  the  vesicular  walls  by  forced  expiration — 
tlie  theory  of  expiration.  But  for  either  of  these  theories  to  be 
operative  the  lung  structure  must  be  congenitally  weak,  for  if  violent 
respiratory  efforts  alone  were  the  essential  factor,  the  disease  would 
be  much  more  frequent. 

What  is  known  as  vicarious  emphysema  is  a  distention  of  the  air 
cells  of  the  healthy  portion  of  the  lung,  some  other  part  being  the 
seat  of  consolidation. 

Interlobular  emphysema  is  the  presence  of  air  in  the  spaces  between 
the  lobules  of  the  lungs  underneath  the  pulmonary  pleura. 


DISEASES   OF   THE   BRONCHIAL  TUBES.  311 

Path.olog'ical  Anatomy.  The  situation  of  vesicular  emphy- 
sema is,  in  the  majority  of  cases,  the  superior  portions  of  the  chest, 
and  is  more  marked  on  the  left  side  than  on  the  right. 

An  emphysematous  lung  feels  remarkably  soft  to  the  touch,  and 
upon  cutting  a  dull,  creaking  sound  is  barely  perceptible.  It  is  of  a  pale- 
red  color ;  the  vesicular  walls  are  thinner  and  slighter  ;  the  vesicles 
are  greatly  enlarged,  sometimes  to  the  size  of  a  pea  or  bean,  and  have 
an  irregular  shape,  and  traversing  most  of  these  large  sacs  (dilated 
vesicles)  a  few  delicate  bands,  the  remains  of  the  lacerated  inter- 
alveolar  septa,  are  visible.  With  the  destruction  of  the  septa  many  of 
the  capillaries  are  destroyed,  leaving  the  emphysematous  tissue 
remarkably  bloodless  and  dry. 

In  consequence  of  the  destruction  of  so  many  of  the  capillaries 
the  obstruction  to  the  pulmonary  circulation  becomes  so  great  that 
the  pulmonary  artery  and  right  cavities  of  the  heart  are  greatly  dis- 
tended ;  finally  the  muscular  tissue  of  the  heart  undergoes  granular, 
followed  by  fatty,  degeneration.  The  distention  of  the  veins  results 
in  a  general  venous  stasis,  to  wit :  nutmeg  liver,  congested  kidneys, 
and  gastro-intestinal  catarrh. 

Symptoms.  The  disease  is  often  not  suspected  until  it  is  well 
developed.  The  chief  symptoms  of  vesicular  emphysema  are  diffi- 
culty of  breathi7tg {diysY>T^c&2i) ,  greatly  aggravated  on  exertion  ;  more  or 
less  cough,  the  result  of  an  attending  brotichiiis,  and  the  various 
symptoms  resulting  from  dilatation  of  the  hearty  particularly  cyanosis 
without  marked  distress.  The  discomfort  of  the  patient  is  often  in- 
creased by  paroxysms  of  asthma. 

Inspection.  The  shoulders  are  rounded,  the  intercostal  spaces 
widened,  the  vertical  diameter  elongated,  with  circumscribed  promi- 
nences between  the  clavicles  and  nipples,  often  increased  by  the 
act  of  coughing — the  peculiar  "barrel-shaped"  chest,  characteristic 
of  this  disease. 

The  character  of  the  respiratory  movements  is  marked,  there  being 
but  slight  movement  observed  on  forcible  respiration,  the  chest  hav- 
ing the  constant  appearance  of  a  full  inspiration. 

Palpation.  The  vocal  fremitus  is  diminished,  and  the  cardiac 
impulse  depressed  and  nearer  to  the  sternum. 

Percussion.  The  resonance  is  increased  (hyper-resonant)  over 
all  the  emphysematous  portions,  and,  if  the  whole  lung  be  involved, 
extends  to  the  seventh  or  eighth  rib  anteriorly  and  to  the  twelfth  rib 


312  PRACTICE    OF    MEDICINE. 

posteriorly.  The  hepatic  dullness  may  not  begin  until  the  inferior 
margin  of  the  ribs  is  reached ;  the  cardiac  dullness  is  lessened,  on 
account  of  the  emphysematous  lung  nearly  covering  the  heart. 

Auscultation.  The  vesicular  murmur  is  lucakctied,  and  in  pro- 
nounced cases  ahnost  absent.  If  bronchitis  be  present,  the  inspira- 
tory sound  may  be  rough  or  sibilant  in  character,  but  its  duration  is 
always  shortened.  Expiration  is  always  prolonged,  and  if  bronchitis 
be  present,  may  be  associated  with  more  or  less  pronounced  moist  or 
bubbling  rales. 

The  first  sound  of  the  heart  is  lessened  in  intensity  and  duration, 
the  second  sound  being  sharply  accentuated. 

Diagnosis.  Bronchitis  is  distinguished  from  emphysema  by  the 
absence  of  dyspnoea,  hyper-resonance  of  the  chest,  changes  in  its 
shape,  size,  and  movements,  and  the  disturbance  of  the  circulation. 

Spasmodic  asthma,  by  the  paroxysmal  character  of  the  affection, 
emphysema  being  a  permanent  malady,  with  attacks  of  asthma. 

Cardiac  diseases  due  to  other  causes  than  emphysema  do  not  have 
the  characteristic  physical  signs  of  that  affection. 

Prognosis.  Vesicular  emphysema  is  essentially  a  chronic  disease. 
In  itself  it  rarely  proves  fatal,  but  if  aggravated  from  any  cause,  or  if 
associated  with  frequent  or  prolonged  asthmatic  paroxysms,  the  car- 
diac changes  are  hastened,  general  dropsy  supervenes,  death  occur- 
ring from  exhaustion,  or,  more  commonly,  as  the  result  of  intercurrent 
attacks  of  pneumonia. 

Treatment.  It  being  impossible  to  restore  the  altered  lung  struc- 
ture, the  indications  for  treatment  are  to  relieve  the  symptoms  and  to 
endeavor  to  prevent  its  further  progress. 

For  the  relief  of  the  asthmatic  paroxysms,  morphines  sulphas  com- 
bined with  atropines  sulphas  may  be  used  hypodermically,  or  ext. 
quebracho  fld.,  f^ss-j  (2-4  Cc.)  every  hour  until  relief;  caffeina 
citrata,  gr.  ij-v  (0.13-0.3  Gm.),  repeated,  or  a  combination  of  nitro- 
glycerinum,  strych?iincE  sttlphas,  and  fnorphince  sulphas,  or  large  doses 
oi  potassiiun  iodidum,  frequently  repeated,  or  inhalations  of  oxygen. 

For  attacks  of  bronchial  catarrh  use  : 

li .     Ammonii  chloridi, 3  ij  8.  Gm. 

Tinct.  hyoscyami, f.5'v  15.  Cc. 

Glycerini, f sj  30.  Cc. 

Syr.  prun.  virg.,      ad  f.^iv  ad  120.  Cc. 

SiG. — Half-tablespoonful  every  few  hours,  well  diluted. 


DISEASES   OF   THE   BRONCHIAL   TUBES.  313 

To  prevent  the  progress  of  the  affection,  remove  the  bronchial 
catarrh,  relieve  the  difficulty  of  breathing,  and  strengthen  the  cardiac 
action,  no  one  combination  seems  comparable  with  the  following: 

R.      Potassii  iodidi, gr- v  -3       Gm. 

Strychninse  sulph. , ^-  zi.  .002  Gm. 

Liq.  potassii  arsenit.,  ....    Tr\^v  .3       Cc. 

Aq.  lauro-cerasi, f 3J  4.        Cc. 

SiG. — Four  times  a  day,  well  diluted. 

But  of  all  means  hitherto  proposed  for  the  relief  of  emphysema, 
nothing  has  approached  the  inhalation  of  compressed  air,  by  means 
of  the  apparatus  of  Waldenberg. 

For  attacks  oi  cyanosis  a  free  venesection  often  saves  life,  combined 
with  and  followed  by  full  doses  of  spiritus  gionoifii. 

The  dropsy  arising  from  failure  of  the  heart  to  compensate  for  the 
circulatory  derangement  in  the  lungs  may  be  relieved  for  a  time  by 
the  use  of  digitalis  and  strychnincB  sulphas,  or  caffeines  citrata,  the  last 
two  being  cardiac  and  respiratory  tonics  and  stimulants,  and  the  last 
mentioned  also  a  diuretic. 


HEMOPTYSIS. 

Synonyms.  Bronchial  hemorrhage;  broncho-pulmonary  hemor- 
rhage ;  bronchorrhagia. 

Definition.  The  expectoration  of  pure  or  unmixed  blood,  usually 
of  a  bright  red  color,  following  the  act  of  coughing. 

Causes.  In  the  majority  of  cases,  the  result  of  ttibercular  deposi- 
tion in  the  walls  of  the  minute  bronchial  arteries  ;  excessive  car.diac 
action ;  bronchial  congestion  ;  excessive  bodily  exertion,  straining, 
lifting,  or  running;  a  symptom  of  hcemophilia  ("bleeder's  disease  "). 

Pathological  Anatomy.  Hsemoptysis  rarely  causes  death  in 
itself,  so  that  few  opportunities  for  observing  post-mortem  appear- 
ances are  obtained,  and  when  they  do  occur,  the  location  of  the 
hemorrhage  is  seldom  found. 

The  air  passages  are  more  or  less  filled  with  clotted  blood ;  the 

mucous  membrane  is  swollen,  and  of  a  dark-red  color ;  rarely,  pale 

and  bloodless.     The  air  cells  contain  blood  clots,  or  are  distended 

with  air,  the  bronchi  being   filled  with  clots,  preventing  its  escape. 

27 


314  PRACTICE    OF    MKDiriNE. 

Unless  the  clots  are  rapidly  removed  by  expectoration  or  absorption, 
a  secondary  inflammation  develops  around  about  them. 

Symptoms.  "Spitting  of  blood  "  occurs  suddenly;  rarely,  it  is 
preceded  by  epistaxis,  cardiac  palpitation,  and  some  difficulty  of 
breathing. 

It  begins  with  a  sensation  of  warmth  under  the  sternum,  tiikiirt^ 
in  the  throat,  2t.  sweetish  taste  in  the  mouth,  an  attempt  to  remove 
which  by  the  act  of  coughing  is  followed  by  a  warm,  saltish,  brit^hl 
red,  frothy  liquid  gushing  from  the  mouth  and  nose.  The  quantity 
of  blood  raised  varies  from  an  ounce  to  a  pint.  The  appearance  of 
the  blood  depresses  the  individual,  he  becoming  pale,  tremulous, 
often  fainting. 

The  attack  may  subside  within  half  an  hour  to  several  hours,  re- 
turning for  several  days,  in  the  meantime  the  expectoration  being 
either  bloody  or  streaked  with  blood. 

A  slight  febrile  reaction,  with  chest  pains,  supervenes  upon  the 
hemorrhage,  the  result  of  the  inflammation  at  the  site  of  the  bleeding, 
which  soon  subsides,  except  where  blood  clots  develop  a  secondary 
pneumonia,  which  may  undergo  the  cheesy  metamorphosis. 

Auscultation.  Coarse,  bubbling  rales  are  heard  in  circumscribed 
portions  of  the  chest. 

Diagnosis.  From  epistaxis,  or  hemorrhage  from  the  posterior 
nares,  it  is  distinguished  by  the  absence  of  air  bubbles  and  an  inspec- 
tion of  the  fauces  and  the  nasal  cavities. 

Hcematemesis,  or  hemorrhage  from  the  stomach,  differs  from 
haemoptysis  in  the  blood  being  vomited  instead  of  expectorated,  of  a 
dark  color,  clotted,  mixed  with  the  acid  contents  of  the  stomach,  fol- 
lowed with  black,  tar-like  stools,  and  the  absence  of  rales  in  the 
chest. 

Exceptions  to  the  above  occur  when  the  blood  from  the  lungs  is 
first  swallowed  and  afterward  raised  by  vomiting,  or  when  the  hemor- 
rhage in  the  stomach  is  caused  by  the  erosion  of  a  large  artery,  the 
result  of  ulcer  of  the  stomach  ;  in  these  cases,  however,  the  raising  of 
blood  is  preceded  by  epigastric  pain  and  the  blood  is  not  frothy. 

Prognosis.  Hiemoptysis  in  itself  rarely  terminates  fatally,  al- 
though causing  much  depression  ;  the  patient  rapidly  recovers,  unless 
secondary  pneumonia  results.  In  nine  cases  out  often  it  is  the  diag- 
nostic sign  of  phthisis. 

Treatment.     Perfect  rest  in  bed,  the  head  and  shoulder  elevated, 


DISEASES   OF  THE   BRONCHIAL   TUBES.  315 

and  perfect  quiet,  the  diet  to  be  bland,  the  drinks  cool,  the  patient 
slowly  swallowing  small  particles  of  ice.  An  ice  bagovtr  the  chest, 
if  it  does  not  cause  chilliness,  is  sometimes  valuable.  Common  salt, 
slowly  dissolved  in  the  mouth,  is  a  popular  remedy,  and,  if  of  no  real 
benefit,  serves  to  occupy  the  attention  of  the  patient  and  friends  until 
medical  advice  is  obtained. 

The  hypodermic  injection  of  atropines  sulphas,  gr.  -^^  (o.ooi  Gm.), 
will  usually  at  once  control  a  hemorrhage.  It  may  be  repeated  pro 
re  nata.  The  one  per  cent,  solution  of  nitro-glycerinum  (spiritus 
glonoini),  in  half  to  minim  doses  every  half  hour  till  relief,  often 
promptly  stops  a  hemorrhage. 

The  hypodermic  injection  of  ergotiti,  gr.  x-xxx  (0.6-2  Gm.),  or 
the  internal  administration  of  extractuni  ergotce  Jluidian,  3ss-j  (2-4 
Cc),  are  recommended,  but  I  consider  them  injurious. 

R.     Acidi  gallici, gr.  xv  i.     Gm. 

Acidi  sulphurici  dil., rt\^x  .6  Cc. 

Aquae  cionamomi, fji'''  ''5-     Cc. 

SiG. — Repeated  every  fifteen  or  twenty  minutes. 

Or  tinctura  matico,  fjj  (4  Cc),  or  extractum  hqmamelis fld.,  TTLxx-f^j 
(1.3-4  Cc),  alunten,  gr.  xx  (1.3  Gm.),  acidum  gallicimi,  gr.  v-x 
(0.3-0.6  Gm.),  or  oleum  terebinthincE ,  TTLv-xv  (0.3-1  Cc),  frequently 
repeated. 

If  the  hemorrhage  causes  great  nervous  excitement  or  depression, 
morphitia,  either  hypodermically  or  internally,  to  quiet  the  patient,  is 
indicated. 

Inhalations,  by  means  of  the  steam  atomizer,  of  either  MonseFs 
solution  or  tinctura  ferri  chloridum,  are  recommended  when  the 
above  means  fail. 

Prof.  Da  Costa  recommends,  for  frequent  small  hemorrhages,  con- 
tinuing day  after  day,  cupri  sulphas  [gr.  -^^  (0.005  Cm.)],  ext.  opii  [gr. 
tV  (0.005  Gm.)],p.  r.  n. 


316  PRACTICE   OF    MEDICINE. 


DISEASES  OF  THE  LUNGS. 


CONGESTION  OF  THE  LUNGS. 

Synonyms.     Pulmonary  engorgement ;  hypostatic  congestion. 

Definition.  An  increase  in,  or  abnormal  fullness  of,  the  capil- 
laries of  the  air  cells  ;  active  congestion  when  the  result  of  an  accel- 
erated circulation  ;  passive  congestion  when  caused  by  an  impeded 
outflow  from  the  capillaries. 

Causes.  Active.  Increased  cardiac  action  ;  over-exertion  ;  alco- 
holic excesses  ;  mental  excitement ;  inhalation  of  cold  or  hot  air. 

Passive.  Obstruction  to  the  return  circulation.  Dilated  heart;  val- 
vular diseases;  low  fevers  (hypostatic  congestion);  Bright's  disease. 

Pathology.  The  congested  or  engorged  lung  has  a  bloated, 
dark-red  appearance  ;  its  vessels  are  distended  to  the  uttermost,  the 
tissues  succulent  and  relaxed,  blood  flowing  freely  over  the  cut  surface ; 
a  bloody,  frothy  liquid  is  present  in  the  bronchi,  and  the  alveolar 
walls  are  so  much  swollen  that  the  condensed  lung  shows  scarcely 
any  indication  of  its  cellular  structure,  resembling  the  tissue  of  the 
spleen  {splenificatioti). 

Symptoms.  Active.  Rapidly  developing  thoracic  distress  and 
difficulty  of  breathing,  flushed  face  /  strong,  full  pulse;  throbbing  caro- 
tids, cardiac  palpitation,  and  congested  eyes,  with  a  short,  dry  cough, 
followed  by  scanty,  frothy  expectoration,  slightly  streaked  with  blood. 

Passive.  Developed  slowly,  with  difficulty  of  breathing,  blueness 
of  the  surface,  almost  continuous  hacking  cough,  followed  by  scanty, 
blood-streaked  expectoration. 

Percussion.  The  resonance  of  the  lungs  slightly  diminished,  the 
quality  of  the  sound  being  somewhat  tympanitic. 

Auscultation.  The  vesicular  murmur  is  diminished  and  accom- 
panied by  sub-crepitant  rales. 

Duration.  Active.  Usually  from  three  to  five  days,  terminating 
either  by  resolution,  hemorrhage,  or,  rarely,  pneumonia.  The  onset 
may  be  so  severe  and  overwhelming  that  death  rapidly  supervenes. 

Passive.  Developed  slowly,  and  subject  to  great  variations,  de- 
pending upon  the  cause. 


DISEASES   OF  THE   LUNGS.  317 

Diagnosis.  Active  congestion  of  the  lungs  cannot  be  distin- 
guished from  the  stage  of  engorgement  of  a  true  pneumonia. 

Prognosis.  An  acute  congestion  of  the  lungs  may  prove  fatal 
within  a  few  hours,  but  under  prompt  treatment  it  generally  terminates 
favorably. 

The  passive  form  is  controlled  entirely  by  the  cause. 

Treatment.  Active.  In  the  strong  and  vigorous  wet  cups  to  the 
chest,  or,  if  the  symptoms  are  pronounced,  a  ^'&x\&x2\  venesection,  and 
ice  bags  over  chest  and  heart.  Internally ,  tinctura  aconiti,  t^j-ij 
(0.06-0.12  Cc),  every  half  hour  or  hour,  as  indicated,  with  free 
catharsis  with  saline  purgatives. 

Passive.  Dry  or  wet  cups  over  the  chest,  hydragogue  cathartics, 
and  the  internal  administration  of  digitalis  and  strychfiince  sulphas  ; 
if  much  depression  of  the  vital  powers,  stimulants,  such  as  spiritus 
frumenti  and  spiritus  ammonicB  aromaticus,  are  indicated. 


CEDEMA  OF  THE  LUNGS. 

Synonym.     Pulmonary  cedema. 

Definition.  An  exudation  of  serum  into  the  pulmonary  interstitial 
tissue  and  the  alveoli  of  the  lungs ;  characterized  by  dyspnoea,  cough, 
and  a  frothy,  blood-streaked  expectoration. 

Causes.  Pulmonary  oedema  is  the  result  of  stasis,  occurring  when 
the  outflow  of  venous  blood  in  the  lung  meets  an  obstacle  that  cannot 
be  overcome  by  the  right  ventricle,  as  in  cardiac  diseases,  in  which 
the  left  ventricle  fails.  Bright's  disease;  alcoholic  excesses,  causing 
cardiac  depression.     Sequelae  to  other  lung  inflammations. 

Patholog'ical  Anatomy.  The  lung  tissue  is  swollen,  and  does 
not  collapse  when  the  chest  is  open.  The  elasticity  of  the  tissue  has 
disappeared,  and  it  pits  upon  pressure. 

If  following  acute  congestion  of  the  lungs,  the  color  is  red ;  if  a 
symptom  of  a  general  dropsy,  its  color  is  pale. 

On  cutting  into  the  oedematous  spots,  an  enormous  quantity  of 
albuminous  fluid,  sometimes  clear,  at  other  times  of  a  red  color,  mixed 
more  or  less  with  blood,  flows  over  the  cut  surface.  The  liquid  is  filled 
with  bubbles,  is  frothy,  from  being  copiously  mixed  with  air,  provid- 
ing the  air  cells  have  not  been  entirely  filled  with  serum,  thereby 
excluding  the  air. 


318  PRACTICE    OF    MF.DICINK. 

Symptoms.  The  pre-eminent  symptom  is  dyspna'a,  the  breath- 
ing being  hurric-d,  labored,  and  ratiling,  all  the  accessory  muscles  of 
respiration  being  called  into  action.  The  setise  of  oppression  and 
anxiety  is  extreme.  There  is  also  a  constant,  harassin<^,  short  cough, 
and  the  expectoration  is  a  blood  streaked,  frothy  mucus.  The  action 
of  the  heart  may  be  tremulous  or  feeble.  The  face  is  at  first  flushed, 
but  as  the  left  ventricle  fails,  or  if  the  effusion  into  the  air  cells  be 
sufficient  to  prevent  the  entrance  of  air,  symptoms  o(  cyanosis  rapidly 
supervene,  the pu/sehecom\ngfeeb/e,  the  surface  cold,  the  breathing 
shaltozu  and  hurried,  the  cough  suppressed,  stupor  replacing  the  rest- 
lessness, soon  deepening  \nio  cotiia. 

Percussion.  If  no  other  lung  disease,  the  percussion  note  is  but 
slightly,  if  at  all,  impaired. 

Auscultation.  The  vesicular  murmur  is  lost  by  the  diffused  sub- 
crepitant  z.x\di  bubbling  rales. 

Diagnosis.  Acute  pncuvtonia  in  the  earlier  stages  is  the  only 
condition  likely  to  be  confounded  with  oedema  of  the  lungs,  but  as 
the  two  diseases  progress,  the  picture  of  pulmonaiy  oedema  is  so 
characteristic  that  it  cannot  be  mistaken. 

Prognosis.  Grave,  and  particularly  if  occurring  in  pneumonia, 
cardiac,  or  Bright's  disease.  In  the  majority  of  instances  it  is  a 
terminal  symptom  coming  on  in  all  forms  of  acute  and  chronic 
diseases. 

Treatment.  As  a  rule,  remedies  are  useless.  The  indication  is 
to  hold  up  the  left  heart,  and  this  is  best  done  by  hypodermic  injec- 
tions of  atropines  sulphas,  gr.  j^^j  (o.ooi  Gm.),  repeated,  which  often 
has  an  almost  magical  effect  ;  or  strychnines  sulphas,  gr.  -^^  (0.0035 
Gm.),  repeated  every  half  hour;  caffeines  cilrata,  gr.  iij-v  (0.2- 
0.3  Gm.),  sparteines  sulphas,  gr.  j-ij  (0.065-0.13  Gm.),  every  hour  or 
two  ;  or  digitalinum ,  gr.  -^^—^^  (0.001-0.002  Gm.),  repeated  every  hour 
or  two.  One  or  more  of  these  drugs  may  be  advantageously  com- 
bined. Occasionally  relief  follows  a  free  venesection  or  the  appli- 
cation of  wet  cups.  Alcoholic  stimulants  are  often  invaluable,  as  is 
spiritus  aminonicB  aromaticus,  frequently  repeated. 

The  above  means  may  be  aided  by  counter-irritation  to  the  chest, 
or  ice-poultices,  hot  mustard  foot-baths, 2.ci\v&  saline  purgatives,  diu- 
retics, and  inhalations  of  oxygen. 


DISEASES  OF  THE   LUNGS.  319 


CROUPOUS  PNEUMONIA. 

Synonyms.  Lobar  pneumonia  ;  pneumonitis  ;  fibrinous  pneu- 
monia ;  pleuro-pneumonia  ;  lung  fever ;  winter  fever. 

Definition.  An  acute,  infectious,  croupous  inflammation,  involv- 
ing the  vesicular  structure  of  the  lungs  rendering  the  alveoli  imper- 
vious to  air ;  characterized  by  a  severe  chill,  headache,  fever,  thoracic 
pain,  dyspnoea,  cough,  rusty  sputum,  and  great  prostration. 

Causes.  Croupous  pneumonia  is  an  infective  disease  caused  by 
the  diplococcus  pneumonicE  of  Fraenkel,  "  which  has  its  seat  of  elec- 
tion in,  and  produces  its  chief  effects  on,  the  lung."  The  micro- 
organism is  found  in  the  sputum  and  in  the  lungs  in  the  majority  of 
cases.  "  Occasionally  other  micro-organisms  seem  to  occasion  typi- 
cal fibrinous  pneumonia.  Among  these  are  the  pneumococcus  of 
Friedlander,  streptococci,  staphylococci,  the  bacillus  of  typhoid 
fever,  the  bacillus  of  influenza,  and  the  bacillus  coli  communis.  In 
some  cases  in  which  bacteria  other  than  the  diplococcus  are  supposed 
to  be  the  cause  there  is  doubtless  mixed  infection,  but  it  must  be 
accepted  at  the  present  time  that  a  number  of  micro-organisms  are 
capable  of  causing  the  disease."     (Stengel.) 

All  ages  liable.  Males  more  frequently  affected  than  females.  One 
attack  predisposes  to  another.  Debilitating  causes  render  individuals 
more  susceptible.  Alcoholism  is  among  the  most  frequent  predispos- 
ing factors.  It  is  most  frequent  in  winter,  at  times  occurring  epidemi- 
cally, the  result  of  atmospheric  conditions  ;  exposure  to  draughts  and 
cold.     Gout,  rheumatism,  diabetes,  and  Bright's  disease. 

Pathological  Anatomy.  The  most  frequent  seat  of  croupous 
pneumonia  is  the  lower  right  lobe ;  the  next  most  frequent  seat  is  the 
lower /^/ lobe  ;  the  next,  the  upper  right  lobe,  although  in  children 
and  the  aged  this  lobe  is  affected  equally  as  often  as  the  right  lower 
lobe. 

The  changes  are:  \.  Hyperemia  (engorgement);  II.  Exudation 
(red  hepatization);  III.  Resolution  (gray  hepatization);  or  it  may 
undergo  purulent  transformation  or  the  development  of  abscesses 
(yellow  hepatization). 

I.  Stage  of  hyper  cemia  :  Congestion,  or  engorgement,  consists  in  the 
vessels  of  the  alveoli  being  distended,  encroaching  upon  the  cavity 
of  the  air  vesicle ;  the  lung  has  a  reddish-brown  color,  is  heavier, 


320  PRACTICE    OF    MKmCINE. 

sinking  somewhat  lower  in  water  than  a  normal  lung,  and  having  a 
slight  exudation  upon  the  vesicular  surface.  The  same  changes  are 
seen  in  the  adjacent  bronchioles. 

II.  S/ci^e  of  exudation  :  Consists  in  the  exudation  of  a  viscid,  fibrin- 
ous fluid,  mixed  with  white  and  red  corpuscles  and  blood,  which 
rapidly  coagulate,  firmly  enclosing  the  corpuscles  and  completely 
filling  the  alveoli.  When  the  exudation  and  coagulation  are  com- 
pleted, the  lung  is  red,  sinks  at  once  when  placed  in  water,  and  its 
elasticity  is  destroyed.  When  cut  into,  the  color,  density,  and  granu- 
lar appearance  so  closely  resemble  the  cut  surface  of  a  section  of  the 
liver  that  Laennec  termed  the  conditoin  red  Jtepatization. 

A  thin  section  shows  under  the  microscope,  as  a  rule,  the  lancet- 
shaped  diplococcus  of  Fraenkel,  as  well  as  staphylococci  and  strepto- 
cocci. 

III.  Resolutionox  gray  hepatization  follows  in  the  majority  of  cases, 
the  coagulated  albuminous  exudation  undergoing  liquefaction  and 
absorption,  the  cellular  element  undergoing  a  fatty  degeneration,  the 
greater  part  absorbed,  the  remainder  expelled  during  acts  of  expec- 
toration, the  alveoli  returning  to  their  normal  condition,  both  as  to 
capacity,  function,  and  elasticity. 

If  resolution  be  retarded  and  portions  of  the  coagulated  exudation 
undergo  pundent  transformaiioti,  changing  from  a  yellowish  to  a 
greenish-yellow  color  (yellow  hepatization),  pus  cells  are  rapidly 
formed,  the  part  becoming  a  granular,  fatty  mass.  The  portions  of 
the  lung  not  undergoing  this  purulent  transformation  retain  the  red- 
dish color  with  intermixed  yellowish  patches.  The  purulent  con- 
tents may  be  ejected  in  part,  the  remainder  undergoing  fatty  degen- 
eration and  finally  absorption. 

Abscess  of  the  lung  may  result  from  the  lung  structure  becoming 
involved  in  the  purulent  disintegration.  Abscesses  may  be  solitary 
or  in  great  numbers,  which  by  disintegration  of  intervening  structure 
form  one  or  more  large  abscesses;  these  abscesses  either  terminate 
fatally  or  open  into  the  pleural  cavity,  causing  e7)ipyema  and  exhaus- 
tion, or  open  into  the  bronchi  and  are  expectorated,  or  an  interstitial 
pneiDHoiiia  is  developed  and  the  abscess  encapsulated  in  a  firm  cica- 
tricial tissue. 

Gangrene  of  the  lungs  may  result  from  blocking  up  of  the  bron- 
chial or  pulmonary  arteries  by  coagula  during  any  stage  of  the  dis- 
ease. 


DISEASES   OF  THE  LUNGS.  321 

The  uninflamed  portions  of  the  lungs  are  hypersemic  and  their 
functional  activity  is  increased. 

Death  sometimes  results  from  a  general  cedema  of  the  unaffected 
lung,  such  cases  being  often  erroneously  termed  "  double  pneumonia." 

If  inflammation  of  the  pleura  be  associated  with  a  pneumonia,  the 
so-called  pleuro-pneutnonia,  the  changes  in  the  pulmonary  pleura  are 
characteristic.  "  An  uneven,  thin,  downy-looking  layer  of  plastic 
exudation  covers  its  surface.  This  plastic  layer  may  conceal  the 
liver-brown  color  of  the  pneumonic  lung.  As  the  third  stage  is 
reached,  the  opposing  surfaces  of  the  pleura  may  become  agglutinated. 
The  pleuritic  changes  follow  very  closely  those  which  occur  within 
the  lung.  The  cells  in  the  pleuritic  exudation  are  mainly  pus.  The 
pleuritic  membrane  is  opaque,  congested,  and  ecchymotic.  It  may 
become  so  thick  as  to  give  a  dull  note  on  percussion,  after  resolution 
is  reached." 

Duration  of  Stages :  stage  of  congestion,  from  one  to  three  days ; 
stage  of  exudation,  from  three  to  seven  days;  stage  of  resolution, 
from  one  to  three  weeks. 

In  severe  cases  or  in  the  very  young,  the  aged,  or  the  depressed, 
the  stage  of  red  hepatization  may  be  fully  developed  within  forty-eight 
hours. 

Endocarditis,  either  simple  or  malignant,  is  a  common  association. 
Pericarditis  is  frequent.     The  spleen  is  usually  enlarged  and  soft. 

Syraptoms.  Begins  with  a  severe  and  usually  protracted  chill 
(in  children  often  convulsions,  adults  vomiting),  followed  by  a  rapid 
rise  of  temperature ,  io3°-io4°  F.  ;  a  strong,  full,  but  rapid  pulse,  soon 
showing  evidence  of  embarrassed  cardiac  action  from  obstructed 
pulmonary  circulation,  either  a  dull  or  sharp  pain  near  the  nipple, 
aggravated  by  pressure,  breathing,  or  coughing ;  shortness  of  breath, 
the  inspiration  short  and  superficial,  the  expiration  accompanied  by 
a  moan  or  grunt,  the  number  of  respirations  increasing  to  40,  50,  or 
more  a  minute,  causing  interrupted  speech  ;  the  ratio  between  pulse 
and  respiration  maybe  i  to  2  or  more  ;  cough,  first  short,  ringing,  and 
harsh,  followed  by  a  scanty,  frothy  mucus,  soon  becoming  semi- 
transparent,  viscid,  and  tenacious,  about  the  second  day  changing  to 
the  familiar  rusty  sputum,  becoming  more  copious  and  of  a  yellow 
color  as  the  disease  advances ;  rarely  cases  occur  with  bloody  or 
blood-streaked  sputum  during  the  continuance  of  the  fever.  There 
are  present  headache,  sleeplessness,  rarely  delirium  (early  delirium  is 
21 


322  PRACTICE    OF    MKDICINE. 

a  grave  sign),  save  in  drunkards;  epista.xis, flushed counlenance,  and 
especially  over  the  malar  bones  is  a  weildelined  mahogany  blush; 
gastric  disturbances  and  scanty,  high-colored  urine,  with  diminiihed 
chlorides,  and  often  albuminuria. 

From  the  very  onset  of  the  disease  the  prostration  is  of  the  most 
pronounced  character. 

The  symptoms  continue  more  or  less  marked  until  either  the 
fifth,  seventh,  ninth,  or  eleventh  day,  when  7i  crisis  occurs,  and  within 
twenty-four  hours  convalescence  is  established,  recovery  rapidly  fol- 
lowing. 

Typhoid  pneumonia  is  a  term  applied  to  those  cases  which  are 
accompanied  by  signs  of  extreme  prostration,  delirium,  tref/ior,  very 
high  temperature,  and  profuse  s.r\d. prolonged  exudation.  They  may 
also  terminate  by  a  crisis. 

Bilious  pneumonia  occurs  in  cases  accompanied  by  congestion  of 
the  liver  or  bile  ducts ;  the  result  of  venous  stasis  from  pulmonary 
obstruction  or  from  an  accompanying  acute  catarrhal  Jaundice.  In 
malarial  districts  pneumonia  and  malaria  are  often  associated,  when 
jaundice  more  or  less  pronounced  occurs.  Such  cases  are  termed 
malarial  or  intermittent  pneumonia. 

Alcoholic,  or  pneumonia  of  the  intemperate,  has  one  very  charac- 
teristic symptom,  to  wit :  early  delirium.  In  pneumonia  generally 
the  mind  is  clear,  even  when  all  the  conditions  are  unfavorable. 
Pneumonia  of  the  intemperate  may  begin  with  symptoms  closely 
resembling  an  attack  of  delirium  tremens,  cough,  expectoration,  and 
pain  being  very  slight,  or  even  absent. 

\{  purulent  infiltration  follow  the  stage  of  red  hepatization,  instead 
of  the  crisis,  symptoms  of  exhaustion  occur,  with  profuse  purulent  ex- 
pectoration, high  temperature,  severe  sweats,  the  tongue  brown  and 
dry,  sordes  collecting  on  the  teeth,  low  delirium,  feeble  pulse,  rapid, 
rattling  breathing,  the  recovery  slow,  and  convalescence  tedious. 

Pneumonia  in  the  aged  or  the  insane  may  be  latent,  coming  on 
without  chill  or  pain  and  with  only  a  slight  fever  ;  the  cough  and  ex- 
pectoration are  slight,  physical  signs  ill-defined  and  changeable,  and 
the  constitutional  symptoms  out  of  all  proportion  to  the  amount  of 
lung  involved. 

Apyretic pneumonia  are  attacks  minus  fever,  the  result  of  exhaus- 
tion and  the  depressing  effect  of  the  infecting  agent  on  the  nervous 
system. 


DISEASES   OF  THE   LUNGS.  323 

Aspiration  pneumonia  is  due  to  the  aspiration  of  fluids  of  any  kind, 
the  disease  being  really  of  mechanical  origin. 

Traumatic  pneumonia  is  the  variety  resulting  from  severe  contu- 
sions of  the  chest,  the  trauma  predisposing  to  the  disease  by  mechan- 
ical injury  of  the  lung,  the  diplococcus  finding  suitable  nidus  at  the 
site  of  injury. 

Inspection.  First  stage,  deficient  movement  of  the  affected  side, 
due  to  pain. 

Second  stage,  the  healthy  side  rises  normally,  the  affected  side  lag- 
ging behind.  If  both  lower  lobes  are  impervious  to  air,  the  diaphragm 
cannot  descend  and  the  epigastrium  does  not  project  during  inspira- 
tion, the  breathing  being  conducted  by  the  upper  part  of  the  chest 
(superior  costal  respiration). 

Palpation.  First  stage,  the  vocal  fremitus  more  distinct  than 
normal. 

Second  stage,  the  vocal  fremitus  is  markedly  exaggerated  except  in 
those  rare  instances  of  occlusion  of  the  bronchi  by  secretion. 

The  cardiac  impulse  is  felt  in  the  normal  position. 

Percussion.  First  stage,  the  percussion  note  is  slightly  impaired, 
indeed,  at  times  having  a  hollow  or  tympanitic  quality. 

Second  stage,  dullness  over  the  affected  parts,  with  an  increased 
sense  of  resistance. 

Auscultation.  First  stage,  over  affected  part,  feeble  vesicular 
murmur,  associated  with  the  true  vesicular  or  crepitant  (crackling) 
rale,  most  distinct  during  inspiration. 

Second  stage,  harsh,  high-pitched,  bronchial  respiration,  at  times 
resembling  a  to-and-fro  metallic  sound,  except  in  those  rare  instances 
in  which  the  bronchi  are  more  or  less  filled  with  secretion. 

Bronchophony,  or  distinctly  transmitted  voice,  at  \.\me.s pectoriloquy, 
or  distinct  transmission  of  articulated  sounds,  is  present. 

Third  stage,  breathing  changing  from  bronchial  to  vesiculo-bron- 
chial,  the  crepitant  {qx&'^\\.2X\o  redux)  rale  returning,  and  if  resolution 
proceed,  the  breath  sounds  are  associated  with  large  and  small  moist 
and  bubbling  rales. 

"  The  morbid  phenomena,  physical  signs,  and  symptoms  of  the 
malady  correspond  usually  in  this  matter."     (Da  Costa.) 


324  PRACTICE    OF    MEDICINE. 

I.    SlaKi;  of  ciiKorgenicnl     Crepitant  rftle  ;  slight  per-    Cough;  bc);inirni);<lyspnoea 
nii>l  lK-i;iiming   exu-        cussion  dullness.  and     rapidly    developed 

dation.  fever  heat. 

I 
II.    Stage  of  solidification     Percussion  dullness  ;  bron-    Rusty-colored    sputum; 
of  lung  tissue   (red        cliial  respiration  ;    bron-        dyspnoea  ;  cough  ;    high 
hepatization).  chophony.  fever  with  marked  even- 

ing   exacerbations     and 
morning  remissions. 

III.    Stage     of     softening    The  same  physical  signs  as  Chills;     prostration,    etc.; 

(gray  hepatization).        in  the  second  stage,  un-  purulent     or     brownish 

less  large  abscesses  have  sputum  ;    generally  high 

formed.  temperature. 

Terminations.  Asthenic  cases  recover  within  two  weeks.  When 
purulent  infiltration  supervenes,  the  disease  pursues  a  tedious  course 
of  several  weeks'  duration,  with  a  low  exhaustive  fever. 

If  death  occur  during  the  first  or  second  stages,  it  is  usually  the 
result  of  -aiConatcral  cedema  of  the  uninflamed  lung,  or  cardiac  failure 
and  impaired  nerve  force. 

If  abscesses  occur,  there  are  exhausting  sweats,  frequent  cough, 
with  a  large  amount  of  yellowish-gray,  at  times  blood-streaked, 
expectoration. 

Gangrene  of  the  lungs  is  a  rare  termination  ;  it  is  associated  with 
symptoms  of  collapse,  the  expectoration  of  a  blackish,  foetid  charac- 
ter, with  the  physical  signs  of  a  pulmonary  cavity. 

Diag"nosis.  CEdctna  of  the  lungs  may  be  confounded  with  the 
first  stage  of  pneumonia,  but  the  subsequent  history,  its  presence  on 
both  sides,  and  the  waterish  expectoration  and  absence  of  chill  and 
pain  and  the  physical  signs  of  pneumonia  soon  determine  the 
diagnosis. 

Pleurisy  is  oftener  confounded  with  pneumonia  than  any  other  dis- 
ease, the  points  of  distinction  between  which  will  be  pointed  out  when 
discussing  that  aft"ection. 

Complications.  Acute  pleuritis  is  a  frequent  complication  of 
croupous  pneumonia,  occurring  as  often  as  from  ten  to  twenty-five 
per  cent,  of  cases.  The  more  acute  localized  pain,  the  greater  em- 
barrassment of  respiration,  and  the  usual  physical  signs  of  effusion 
are  the  evidences  of  z. pleuro pneumonia. 

Endocarditis  is  a  common  complication,  showing  irregular  but 
protracted  temperature  record,  with  chills  and  sweats  and  great 
embarrassment  of  the  respiration. 


DISEASES   OF   THE   LUNGS.  325 

Capillary  bronchitis  is  a  rare  but  dangerous  complication.  Peri- 
carditis, rheumatism,  and  £'Out  a.re  rare  complications. 

Prognosis.  Depends  upon  the  extent  of  the  inflammation,  the 
dangerous  features  of  croupous  pneumonia  being  cardiac  failure,  the 
result  of  an  endo-  or  myocarditis  or  of  embarrassed  respiratory  circu- 
lation, and  the  rapid  tissue  waste,  associated  with  extreme  fever  (105°), 
resultirg  in  impaired  nerve  force.  Double  pneumonia  has  a  very 
grave  prognosis,  but  it  is  not  nearly  so  frequent  as  was  at  one  time 
supposed.  The  coexistence  of  pleuritis  adds  to  the  gravity  of  the 
prognosis,  although  not  so  fatal  as  generally  supposed.  Pneumonia 
of  drunkards  almost  invariably  terminates  fatally.  Typhoid  pneu- 
monia, pneumonia  of  the  aged  and  in  the  insane,  and  the  so-called 
bilious  pneumonia,  purulent  infiltration,  abscesses  of  the  lungs,  and 
gangrene,  all  give  a  grave  prognosis. 

Treatment.  If  pneumonia  be  regarded  as  a  constitutional  malady 
with  a  local  lesion,  then  the  consolidated  lung  no  more  calls  for  treat- 
ment than  does  the  intestinal  ulcer  of  typhoid  fever,  but  the  general 
condition  of  the  patient  is  to  govern  in  the  management  and  not  the 
local  changes  in  the  thorax.  A  simple  pneumonia  attacking  persons 
previously  in  good  health  requires  no  more  active  treatment  than  any 
of  the  so-called  self-limited  diseases^  provided  only  that  the  extent  of 
the  disease  be  moderate,  and  there  be  no  complication. 

The  much-discussed  question  of  venesection  is  now  a  settled  prob- 
lem in  the  affection  ;  if  we  bleed,  it  is  "  not  because  of  pneumonia,  but 
in  spite  of  pneumonia.'''  Called  to  a  case  in  the  first  stage  or  early  in 
the  second  stage,  who  has  been  vigorous  and  otherwise  healthy,  with 
a  high  temperature,  105°  or  more,  with  frequent  pulse,  one  hundred 
and  twenty  beats  or  more,  or  a  slow,  full  pulse  showing  cardiac 
oppression,  flushed  surface,  and  marked  dyspnoea,  a  copious  bleed- 
ing is  indicated,  and  the  same  may  be  said  when  symptoms  of  collat- 
eral oedema  threaten  ;  this  is  bleeding  for  symptoms  and  not  for  the 
disease  per  se. 

There  is  no  remedy  which  can  exert  a  favorable  influence  upon  the 
pneumonic  process.  Many  cases  recover  without,  and  many  cases  in 
spite  of,  treatment.  When  treatment  is  instituted,  be  guided  by  the 
fact  that  you  are  not  to  treat  pneumonia,  but  a  patient  with  a  pneu- 
monia. 

At  the  onset,  if  venesection  is  not  indicated,  relief  of  the  pain  may 


326  PRACTICE    OF    MEDICINE. 

follow  the  use  of  dry  or  wet  cups.     If  the  tongue  be  coated  and  the 
gastro-intestinal  canal  deranged,  a  calomel  purge  is  indicated. 

K.      llydrargyri  chloridi  mitis,    .    .    .  gr.  ij  .13    Gm. 

Sodii  bicarb. , gr-  iv  .26    dm. 

I'ulv.  ipecac,      .  • gr.  j  .065  Gm.  M. 

Ft.  chart.  No.  iv. 

Sio. — One  every  two  hours,  followed  in  two  hours  after  last  powder  by 
mild  saline. 

Action  on  the  skin  and  kidneys  by  refrigerant  mixtures  or  small 
doses  of  Dover's  powder  is  valuable.  The  administration  of  the 
arterial  sedatives,  aconitum  and  veratrum  viride,  are  recommended 
by  Drs.  Da  Costa  and  H.  C.  Wood.  In  pneumonia  of  children  the 
use  of  small,  frequently  repeated  doses  oi  tinctura  aconiii\x\.  the  early 
stage  is  most  useful. 

Poultices  are  of  slight  value,  but  the  use  of  home-made  mustard 
plasters,  weakened  with  flour,  is  useful  in  all  stages.  If  the  heart  be 
weak  from  the  onset,  either  of  the  following  are  valuable:  digitalis, 
caffeines  ciiraia,  niiro glyceriiiuiii,  spartein,  or  strychnina.  Indeed, 
it  seems  a  good  practice  to  administer  strychnina  in  full  doses  from 
the  onset.  Quinines  sulphas,  gr.  ij-v  (0.13-0.3  Gm.)  every  three  or 
four  hours,  is  always  valuable. 

Second  Stage.  It  is  at  this  period  of  a  severe  attack  of  acute  pneu- 
monia that  two  prominent  indications  for  treatment  arise — heart 
insufficiency  and  high  temperature. 

To  sustain  the  heart  is  one  of  the  most  important  indications,  for 
experience  shows  that  cardiac  failure  is  responsible  for  a  large  num- 
ber of  deaths  in  this  affection.  Strychnines  sulphas,  gr.  ^2~^s  (°  002- 
0.003  Gm.),  repeated  every  few  hours  by  mouth  or  by  the  hypodermic 
method,  or  caffeines  ciirata,  gr.  ij-v  (0.13-0.3  Gm.)  every  four  hours, 
or  tinctura  strophanthus,  Tt\^v-x  (o  3-0.6  Cc.)  every  three  hours,  are 
valuable  cardiac  tonics  in  pneumonia.  The  availability  of  digitalis 
and  nitro-glycerinum  depends  upon  a  careful  study  of  the  pulse.  If 
the  tension  is  low,  the  result  of  relaxation  of  peripheral  blood  vessels, 
— vaso-motor  paralysis, — digitalis  in  full  doses  is  indicated  ;  but  if  the 
tension  is  high,  with  embarrassed  right  heart,  nitro-glycerinum  every 
hour  or  two,  with  spiritus  ammonii  aromaticus,  is  the  indication. 
Alcoholic  stimulatits  judiciously  employed  are  most  efficient  means 
for  preventing  or  overcoming  the  cardiac  failure.     The  amount  can 


DISEASES  OF  THE   LUNGS.  327 

only  be  determined  by  a  careful  study  of  each  case,  as  a  few  ounces 
in  the  twenty-four  hours  may  answer  in  one,  while  another  may 
require  eight  or  ten  ounces.  It  is  well  to  begin  with  small  doses, 
increasing  or  decreasing  as  its  effects  are  good  or  bad.  The  indi- 
cator of  the  heart's  cottdition  is  the  pulse.  In  the  aged,  the  feeble,  or 
in  those  accustomed  to  the  use  of  alcohol,  stimulation  is  indicated 
from  the  onset.  Other  indications  would  be  a  frequent,  feeble, 
irregular,  or  intermitting  pulse  ;  a  dicrotic  pulse  ;  delirium,  muscular 
tremor,  and  subsultus ;  immediately  following  crisis,  and  the  period 
of  collapse. 

To  reduce  the  temperature  is  at  times  an  important  indication.  If 
the  fever  is  under  103°  F.,  cool  sponging  with  alcohol  and  water,  or 
water  alone,  is  sufficient.  If  the  temperature  is  above  104°  F.,  anti- 
febrin,  gr.  v  (0.3  Gm.),  may  be  used  every  three  hours  until  a  reduc- 
tion occurs.  Strychnitice  sulphas,  or  caffeines  citrata,  may  be  added 
to  each  dose.  Phenacetin  or  acetanilidutft  are  also  valuable,  and 
considered  less  depressing,  but  it  is  to  be  remembered  that  a  temper- 
ature under  104°  is  as  normal  to  pneumonia  as  the  dyspnoea  or  the 
rusty  sputum,  and  so  use  antipyretic  drugs  with  caution. 

The  use  of  the  cold  pack  or  of  cold  baths  for  reducing  the  temper- 
ature in  acute  pneumonia  has  not  given  the  success  expected. 

Dr.  Mays  strongly  advocates  the  use  of  ice  bags  to  the  chest  in 
pneumonia.  He  says:  "Very  often  it  is  found  that  the  application 
of  the  ice  to  an  affected  spot  is  immediately  followed  by  a  marked 
lowering  of  the  temperature  and  improvement  in  the  physical  signs 
in  the  part."  I  am  able,  from  an  experience  of  five  years,  to  endorse 
this  statement. 

For  dysp7ioea  and  pain,  a  hypodermic  injection  of  morphince  sul- 
phas, repeated  p.  r.  n.  The  dyspnoea  is  often  relieved  by  inhalations 
of  oxygen,  but  do  not  expect  too  much  from  oxygen  as  there  is  some 
additional  factor  besides  the  mechanical  one  of  consolidation  of  the 
lung  producing  the  dyspnoea,  for  the  consolidation  is  just  as  marked 
immediately  after  the  crisis,  while  the  dyspnoea  is  wonderfully  relieved. 

The  diet  must  be  of  the  most  nutritious  but  easily  digestible  char- 
acter, and  given  at  periods  of  every  three  hours,  watching  that  the 
food  is  assimilated.  A  distended  stomach  and  abdomen  is  danger- 
ous.    Strong  black  coffee  throughout  the  disease  is  valuable. 

Third  Stage.  The  treatment  is  a  continuation  of  that  of  the  second 
stage,  with  the  addition  of  the  following  valuable  combination  : 


328  PRACTICE   OF   MEDICINE. 

IJ .      Ammonii  chloridi, gr.  v-x  .3-.6  Gni. 

Strychnin;v  siilph., gr.  ^'f  -003    ^™- 

Aqua:  chloroformi f^j  4.          Cc. 

Syr.  prun.  virg., f 3 'U  '-•          ^c.          M. 

SiG. — Every  three  hours,  diluted. 

Many  cases  are  favorably  influenced  by  an  expectorant  from  the 
onset  of  the  disease. 

Convalescence.  Nutritious  diet,  quinines  sulphas  in  tonic  doses, 
ferriim,  together  with  a  good  blood-making  wine  or  a  good  prepara- 
tion of  malt.  If  the  consolidation  shows  a  disposition  to  linger, 
blisters  may  be  used. 

The  various  symptoms  other  than  those  particularly  mentioned  are 
to  be  met,  as  they  arise,  by  their  proper  remedies. 

For  typhoid  pneumonia,  purulent  infiltration,  abscess  of  the  lungs, 
or  pneumonia  in  drunkards,  the  weak,  or  the  aged,  qninina:  sulphas, 
ferrum,  nutritiotts  diet  and  bold  stimulation,  and  the  free  use  of 
annnonii  carbonas  or  spiritus  ammonia;  aromaticus,  caffeines  citrata, 
and  strychnines  sulphas, — these  last  two  being  respiratory  and  car- 
diac tonics, — are  the  indications. 

Sleeplessness  is  an  annoying  symptom  frequently  requiring  treat- 
ment. Balfour,  of  Edinburgh,  advocates  chloral.  With  strychnines 
sulphas  it  is  safe  and  satisfactory.  The  same  can  be  said  for  trional 
with  strychnines  sulphas. 

The  so-called  antiseptic  treatment  of  acute  pneumonia  is  still  under 
trial,  and  no  definite  opinion  can  be  expressed  concerning  it. 


CATARRHAL  PNEUMONIA. 

Synonyms.  Broncho-pneumonia;  lobular  pneumonia;  capillary 
bronchitis  (?). 

Definition.  An  acute  catarrhal  inflammation  of  the  bronchioles 
and  alveoli  of  the  lungs,  characterized  by  fever,  cough,  dyspnoea, 
copious  expectoration,  and  great  depression. 

Causes.  From  an  extension  of  a  bronchial  catarrh  downward; 
following  the  eruptive  fevers,  especially  measles  ;  complicating  whoop- 
ing cough.  Persons  of  the  rickety  or  scrofulous  diathesis,  in  whom 
there  is  a  greater  irritability  of  the  epithelial  elements,  are  particularly 
predisposed  to  this  form  of  pneumonia  on  slight  exposure ;  emphy- 


DISEASES   OF  THE   LUNGS.  329 

sema;  diseases  of  the  heart ;  most  frequently  seen  in  childhood  and 
old  age.  The  inspiration  of  particles  of  food  and  mucus  in  the  last 
stages  of  low  diseases — the  aspiration  or  deglutiiioii  pneumonia — is 
of  the  catarrhal  variety. 

Bacteriological  investigations  seem  to  indicate  that  broncho-pneu- 
monia is  due  to  more  than  one  germ,  although  the  diplococcus 
pneumoniae  is  the  most  frequent  etiological  factor. 

Pathological  Anatomy.  Hypercemia  of  the  mucous  membrane 
of  the  bronchi,  extending  to  the  connective  tissue  of  the  bronchioles 
and  accompanying  arterioles  and  to  the  alveoli,  with  swelling  and 
succtdence  oi  Xh^fs^  tissues,  accompanied  by  an  abnormal  secreiioii  and 
an  immense  production  of  young  cells  from  the  proliferation  of  the 
bronchial  and  alveolar  epithelium,  admixed  with  a  yellowish,  creamy, 
mucoid  material,  which  blocks  up  the  bronchioles  and  air  cells. 

The  affected  parts  first  have  a  reddish-gray,  soon  changing  to  a 
yellowish-gray,  color,  due  to  the  rapid  metamorphosis  of  the  newly 
developed  cells.  If  the  fatty  change  be  completed,  absorption  takes 
place  and  the  consolidation  is  removed ;  if  it  remain  incomplete,  the 
cells  atrophy,  the  little  mass  becoming  caseous,  and  the  disease 
passes  into  a  chronic  state. 

The  bronchial  tubes  also  participate  in  the  disease ;  the  walls  be- 
come thickened,  from  a  hyperplasia  of  the  connective  tissue  {^peri- 
bronchitis), and  their  calibre  is  often  dilated. 

Symptonis.  Catarrhal  pneumonia  begins  as  a  catarrhal  bron- 
chitis.    It  may  be  either  acute,  subacute,  or  chronic  in  its  course. 

Acute  variety  :  Its  onset  is  announced  by  a  gradual  rise  of  tem- 
perature to  io2°-io3°  F.,  the  febrile  phenomena  assuming  a  typical 
remittent  character,  with  rapid,  laborious,  and  shallow  breathitig,  as 
shown  by  the  widely  dilated  nares  and  violent  action  of  all  the  acces- 
sory muscles,  while  the  insufficient  distention  of  the  lungs  is  shown 
by  the  great  recession  of  the  lower  part  of  the  chest  walls  and  sinking 
in  of  the  intercostal  spaces.  The  inspiration  is  short  and  imperfect, 
the  expiration  noisy  and  prolonged;  the  pulse  x's,  frequent,  100-120 
or  more,  and  somewhat  compressible ;  the  cough,  which,  during  the 
bronchitis,  was  loose,  now  becomes  short,  hacking,  dry,  and  painful, 
soon  followed  by  more  or  less  copious  wuco-purulent  expectoration  ; 
the  appetite  is  impaired,  bowels  somewhat  loose,  urine  scanty,  high- 
colored,  and  the  surface  frequently  covered  with  a  more  or  less 
profuse  perspiration. 


330  PRACTICE    OF    MEDICINE. 

The  subacute  and  chronic  varieties  have  the  same  general  symp- 
toms, but  the  duration  is  longer  and  the  exhaustion  greater. 

The  progress  of  catarrhal  pneumonia  is  sonielimes,  although  not 
often,  a  very  acute  one.  The  disease  may  prove  fatal  in  a  few  days, 
especially  if  it  attack  feeble  children  ;  in  such  the  countenance  be- 
comes pale  and  livid,  the  lips  bluish,  the  eyes  dull,  and  a  restlessness 
giving  place  to  apathy,  and  a  continually  augmented  somnolence. 

Resolution,  when  it  occurs,  is  by  lysis,  several  weeks  elapsing 
before  complete  recovery. 

Percussion.  Dullness,  scattered  in  patches,  over  both  lungs, 
the  intervening  healthy  lung  often  giving  a  more  or  less  hollow  or 
tympanitic  note. 

Auscultation.  Vesiculo-bronchial  breathing,  changing  to  moist 
bronchial  breathing,  associated  with  small  bubbling  (sub-crepitant) 
rales.  As  the  disease  progresses  toward  resolution,  the  rales  become 
larger  (large  bubbling)  and  more  numerous.  If  pneumonic  phthisis 
result,  physical  signs  indicative  of  that  condition  are  soon  evident. 

Sequelae.  Attacks  of  catarrhal  pneumonia  complicated  with 
atelectasis,  or  collapse  of  the  lobules,  when  recovery  occurs,  are  fol- 
lowed by  emphysema  of  the  lungs. 

If  the  catarrhal  products  which  fill  the  alveoli  and  bronchioles  and 
intervening  connective  tissue  do  not  rapidly  undergo  complete  fatty 
metamorphosis  and  consequent  absorption,  pneumonic  phthisis  re- 
sults. 

Diagnosis.  Ordinary  bronchial  catarrh  differs  from  catarrhal 
pneumonia  by  the  absence  of  dyspnoea,  fever,  and  dullness  on  per- 
cussion, and  the  presence  of  the  large  bubbling  rales,  and  also  by  the 
subsequent  history  of  the  two  affections. 

Croicpoiis  pneumonia  is  a  unilateral  disease  ;  catarrhal  pneumonia 
is  bilateral  and  diffused  over  both  lungs — the  former  a  self-limited 
disease,  the  latter  having  no  fixed  duration. 

Acute  tuberculosis  at  its  onset  is  characterized  by  the  presence  of  a 
capillary  bronchitis,  a  differentiation  being  possible  only  by  a  study 
of  the  clinical  history  and  course  of  the  two  maladies  and  the  presence 
or  absence  of  the  tubercular  bacilli. 

CEdema  of  the  lungs  is  a  bilateral  disease  associated  with  a  short, 
dry  cough,  and  dyspnoea,  but  lacks  the  previous  catarrhal  history  and 
high  temperature  of  catarrhal  pneumonia. 

Prognosis.     Fully  one-half  of  the  cases  of  true  catarrhal  pneu- 


DISEASES   OF  THE   LUNGS.  331 

monia  terminate  fatally.  The  prognosis  must  be  guarded  in  scrofu- 
lous or  rachitic  subjects,  or  those  enfeebled  by  other  diseases,  for, 
unless  prompt  resolution  can  be  effected,  it  will  terminate  fatally 
early,  or  develop  pneumonic  phthisis.  Have  seen  cases  continuing 
up  and  down  for  eight  and  ten  months,  and  finally  make  a  good 
recovery. 

Treatment.  Confinement  to  bed  is  paramount,  although  the 
position  of  the  patient  is  to  be  frequently  changed.  The  diet  must 
be  of  the  most  nutritious  character,  administered  at  frequent  intervals : 
milk,  eggs,  chicken,  beef,  mutton  and  oyster  broths  are  the  most 
suitable  articles.  The  steady  use  of  brandy  or  w-^zj-/^^/ throughout  the 
attack  is  of  importance,  regulating  the  amount  by  the  age  of  the 
patient  and  the  severity  of  the  attack. 

Locally  a  weak  mustard  plaster  followed  with  a  cotton-batting 
jacket  is  valuable.  Poultices  are  of  little  use.  The  febrile  symptoms 
and  early  cough  are  often  modified  by  the  following  mixture : 

R.      Potassii  citratis, ^vj  24.  Gm. 

Spts.  setheris  nitrosi, f^iv  15-  ^'^• 

Tinct.  opii  camphorat., f^i^^  ^S-  Cc. 

Liquor,  potassii  citratis,  ...     ad  f  5  vj  ad  180.  Cc.  M. 

SiG. — Dessertspoonful  every  three  hours. 

Early  in  an  attack,  in  children  with  high  temperature,  tinctura  aconiti, 
in  small,  frequently  repeated  doses  is  valuable.  If  the  fever  persists, 
a  combination  of  phenacetin  or  antifebrin  with  camphor  or  digitalis 
is  useful.  The  ice  bags  or  poultices  are  as  strongly  urged  for  broncho- 
pneumonia as  for  croupous  pneumonia,  and  in  sthenic  cases  should 
be  given  a  trial. 

For  the  catarrhal  process,  the  air  of  the  apartment  should  be  main- 
tained at  an  even  temperature  and  moistened  by  disengaging  the 
vapor  of  water  in  it.  The  following  combination  is  of  great  utility  in 
nearly  all  cases,  regulating  the  dose  in  accordance  with  the  age  of  the 
patient : 


R .     Ammonii  carbonat 
Ammonii   iodidi, 
Mucil.  acacise,     . 
Syr.  glycyrrh. ,    . 
Syr.  prun.  virg., 
SiG. — Every  three  hours 


.    gr.  V  .3        Gm. 

.    gr.  v-x  -S-.S  Gm. 

.     q.  s.  q.  s. 

.  f53  4-          Cc. 

ad  f^iv  ad   15.          Cc. 


A  much  pleasanter  way  of  administering  the  ammonia  salts  is  in 


332  PRACTICE    OF    MKDICINE. 

capsules,  each  containing  about  two  and  one-lialf  grains  of  each  salt 
with  an  aromatic  oil.  lerpinum  hydras  acts  remarkably  well  in 
many  lingering  cases.  The  spiritus  ammonii  aromaticus  in  either 
chloroform  or  cherry-laurel  water  makes  an  excellent  mild,  stimu- 
lating expectorant. 

For  convalescence,  nutritious  food,  ferri  iodidiim,  quini/ur  sulphas, 
and  ohuin  fnorrhiice. 

Locally  :  repeated  application  of  mustard  poultices  or  turpentine 
stupes,  followed  by  cotton  jacket.  If  the  inflammatory  processes  tend 
to  become  chronic,  scattering  blisters  should  be  used. 


PULMONARY  TUBERCULOSIS. 

Synonyms.  Phthisis  pulmonalis  ;  phthisis;  consumption;  pneu- 
monic phthisis;  tubercular  phthisis. 

Definition.  An  infective  disease,  caused  by  the  bacillus  tubercu- 
losis, the  lesions  of  which  are  characterized  by  nodular  bodies  called 
tubercles  or  diffused  infiltrations  of  tuberculous  tissue,  which  undergo 
caseation  or  sclerosis,  and  may  finally  ulcerate,  or,  in  some  situations, 
calcify.     (Osier.) 

Clinical  Varieties.  I.  Acute  miliary  tuberculosis;  II.  Pneu- 
monic phthisis ;  111.  Tubercular  phthisis  ;  IV.  Fibroid  phthisis. 

Cause.  It  is  now  generally  accepted  that  all  varieties  of  pulmon- 
ary consumption  are  due  to  the  active  presence  of  the  bacillus  tuber- 
culosis, discovered  by  Koch  in  1880.  The  lung  tissue  must  be  in  a 
receptive  state,  as  the  bacilli  may  be  present  in  the  respiratory  tract 
without  the  development  of  the  disease. 

Any  condition  that  lowers  the  tone  of  the  general  system  renders 
the  tissues  susceptible  to  the  changes  produced  by  the  tubercle  bacilli. 
These  will  be  enumerated  in  speaking  of  the  clinical  varieties  of  the 
disease. 

ACUTE   MILIARY  TUBERCULOSIS. 

Synonyms.     Acute  phthisis;  galloping  consumption. 

Definition.  An  acute  infective  febrile  affection,  due  to  the  rapid 
eruption  in  various  parts  of  the  body,  but  especially  in  the  lungs,  of 
miliary  tubercles ;  characterized  by  high  fever,  rapid  pulse,  hurried 


DISEASES   OF  THE   LUNGS.  333 

respiration,  pains  in  the  chest,  cough,  profuse  expectoration,  and  rapid 
prostration. 

Causes.     In  the  majority  of  cases  it  is  the  result  of  an  auto-infec-  . 
tion,  arising  from  either  an  active  or  latent  tuberculous  focus.     Cases 
develop  in  which  no  cause  can  be  assigned.     Often  follows  measles, 
whooping-cough,  variola,  and  influenza. 

Most  frequent  between  puberty  and  middle  life. 

"  That  the  gray  granulation  is  deposited  throughout  the  body  under 
the  influence  of  certain  conditions  of  irritation,  it  is  necessary  that  a 
peculiar  vulnerability  of  the  constitution  exist — in  other  words,  that  it 
be  of  the  scrofulous  type." 

Clinical  Forms.  Getieral  or  typhoid,  pulmonary  and  cerebral. 
The  cerebral  will  be  described  in  the  section  on  nervous  diseases. 

Pathological  Anatomy.  Pulmonary  form.  "  The  gray  granu- 
lation or  miliary  tubercle  consists  of  a  fine  reticulation  of  fibres,  with 
a  mass  of  epithelioid  cells  and  granules,  and  often  having  a  giant  cell 
for  its  centre." 

The  deposit  is  generally  over  both  lungs  and  the  bronchial  tubes, 
and  is  followed  by  hypersemia,  increase  of  secretion,  having  a  viscid 
and  adhesive  character,  and  the  destruction  of  all  the  tissue  with  which 
it  comes  in  contact. 

Deposits  also  take  place  in  the  brain,  pleurae,  intestines,  peritoneum, 
and  kidneys. 

G-eneral  or  Typhoid. — Symptoins.  Gradual  progressive  weak- 
ness, with  loss  of  appetite  ;  dry,  clean  tongue  ;  costive  bowels,  flushed 
cheeks  ;  fever,  irregular  in  type,  and  rapid,  feeble  pulse.  Rarely  the 
temperature  reaches  103°  F.,  to  104°  F.,  associated  with  a  mild 
delirium.  The  respirations  are  increased  with  slight  or  no  cough,  and 
little  or  no  expectoration.  Often  the  symptoms  of  a  dififused  bron- 
chial catarrh  of  the  smaller  tubes  are  present.  As  the  symptoms 
continue  the  prostration  increases,  cyanosis  develops,  the  patient 
growing  stupid,  gradually  deepening  into  coma  and  death. 

Diagnosis.  The  symptoms  of  acute  phthisis  point  to  an  acute 
general  infection,  and  the  disease  is  apt  to  be  mistaken  for  typhoid 
fever.  The  points  of  difference  are  the  absence  of  the  typical  typhoid, 
or  step-like,  temperature  record,  the  characteristic  eruption,  and  the 
diarrhoea.  The  differential  diagnosis  can  be  more  readily  determined 
by  the  Widal  test  and  the  diazo  reaction  in  the  urine. 

Prognosis.     Recovery  is  the  rarest  termination. 


334  PRACTICE    OF    MEDICINE. 

Treatment.     Expectant  and  symptomatic. 

Pulmonary  Form.  Symptoms.  The  onset  is  usually  sudden, 
with  a  chill  or  cJiilliness,  followed  by  fever,  io2°-io4°  F.,  riipui, 
dicrotic  pulse,  120-140,  coui^/t,  with  scanty,  glairy  sputum,  vicnased 
respiration,  30-50  per  rnxnuie.,  pain  in  the  chest,  hot  skin,  dry  tongue, 
deranged  digestion,  and  great  prostration,  the  severity  of  the  symp- 
toms rapidly  increasing,  with  evidences  of  cyanosis,  the  sputum 
becoming  more  abundant  and  often  rusty  in  color,  with  more  or  less 
frequent  attacks  of  hamoptysis,  soon  followed  by  headache,  vertigo, 
sleeplessness,  often  delirium,  coma,  and  death. 

If  deposits  have  occurred  in  the  meninges  or  the  intestines  symp- 
toms of  these  affections  are  superadded. 

Percussion.  The  percussion  resonance  is  normal  until  consider- 
able deposits  have  occurred,  when  it  is  either  slightly  impaired  or 
even  slightly  tympanitic.  With  the  development  of  cavities  ihe  am- 
phoric percussion  note  is  present. 

Auscultation.  Often  little  change  in  the  vesicular  murmur,  but 
diffused  rales  of  bronchial  catarrh,  or  vesiculo-bronchial  breathing, 
associated  with  large  and  •s,xn7i\\,mo\'~Xox  bubbling  rales,  soon  followed 
by  bronchial aiTid  brcncho-cavemoics  breathing,  with  large  and  small, 
moist  and  circumscribed  ^i^/^r^/m^  rales. 

Duration.  Acute  phthisis  usually  terminates  fatally  in  from  four 
to  twelve  weeks.     Rarely  of  several  months'  duration. 

Diagnosis.  Commonly  mistaken  for  typhoid  fever  with  lung 
complications,  an  error  that  is  readily  made  unless  a  close  study  of 
the  history,  symptoms,  physical  signs,  and  sputum  be  made.  The 
Widal  test  may  assist  in  determining  the  diagnosis. 

Treatment.  There  are  no  means  of  retarding  the  progress 
of  this  malady.  Loomis  says :  "  Morphia  in  small  doses — 2V 
of  a  grain  (0.003  Gm.)  hypodermically  every  six  or  eight  hours — has, 
in  my  hands,  been  more  satisfactory  in  staying  the  progress  of  the 
disease,  prolonging  life,  and  keeping  the  patient  comfortable  than 
any  other  plan." 

Dr.  McCall  Anderson  claims  that  subcutaneous  injections  of 
atropinae  sulphas  check  the  exhausting  sweats,  and  that  quininae 
sulphas,  digitalis,  and  opium  reduce  the  temperature,  and  if  they  fail, 
ice-cloths  to  the  abdomen  will  accomplish  the  desired  result. 

The  various  symptoms  should  be  met  as  they  occur,  the  patient  at 
the  same  time  being  supplied  with  large  quantities  oi  stimulants,  and 
full  doses  of  strychninae  sulphas  and  arsenicum. 


DISEASES   OF  THE   LUNGS.  335 


PNEUMONIC  PHTHISIS. 

Synonyms.  Chronic  catarrhal  pneumonia  ;  catarrhal  phthisis ; 
caseous  pneumonia  ;  caseous  phthisis. 

Definition.  A  form  of  pulmonary  consumption  characterized  by 
the  destruction  of  the  pulmonary  tissue  resulting  from  the  action  of  the 
bacillus  tuberculosis,  causing  the  caseation  or  cheesy  degeneration  of 
inflammatory  products  in  the  lungs,  and  the  subsequent  softening  and 
destruction  of  the  caseous  matter,  with  greater  or  less  destruction  of 
the  pulmonary  tissue  ;  characterized  by  hectic  fever,  cough,  shortness 
of  breath,  purulent  expectoration,  and  more  or  less  rapid  prostration. 

Causes.  The  predisposing  factor  in  the  etiology  of  pneumonic 
phthisis  is  a  strumous  or  scrofulous  diathesis,  or  a  condition  of  lowered 
health,  the  result  of  various  unfavorable  hygienic  influences. 

The  exciting  causes  are  :  the  irritation  produced  by  the  presence  of 
the  bacillus  tuberculosis  and  a  catarrhal  pneumonia  in  any  portion 
of  the  lung,  but  especially  at  the  apex  ;  inflammation  occurring  about 
a  blood  clot;  inhalation  of  irritant  particles  occurring  in  such  occu- 
pations as  weaving,  grinding,  mining,  milling,  cigar-making,  and 
the  like.  Many  cases  of  pneumonic  phthisis  can  be  traced  to  an 
attack  of  influenza  a  year  or  so  before  in  individuals  having  the 
peculiar  diathesis. 

Pathological  Anatomy.  When  a  pneumonia  terminates  in 
resolution,  the  inflammatory  products  are  absorbed  by  first  undergoing 
2.  fatty  i7ietamorphosis.  If  the  fatty  metamorphosis  be  incomplete,  the 
cells  are  atrophied  and  undergo  the  caseous  degeneration,  which  con- 
sists in  the  absorption  of  the  watery  parts,  the  fatty  degeneration  of 
the  cellular  elements,  and  the  granular  disintegration  of  the  fibrinous 
material,  so  that  ultimately  a  soft,  solid  mass  is  produced,  yellowish 
in  color,  having  the  appearance  of  cheese. 

The  destructive  changes  are  thus  described  by  Niemeyer:  "  Cells, 
the  products  of  inflammation,  accumulated  in  the  alveoli  and  minute 
bronchi,  crowd  upon  each  other,  becoming  densely  packed,  and  thus 
by  their  mutual  pressure  they  bring  about  their  own  decay,  as  well 
as  that  of  the  lung  textures,  by  interfering  with  their  nutrition,  the 
alveolar  walls  being  also  themselves  damaged  by  the  inflammatory 
process." 

The  position  of  the  catarrhal  pneumonia  resulting  in  the  above 


336  PRACTICE    OF    MEDICINE. 

changes  is  usually  at  the  apex  or  under  the  lower  inner  scapular  re- 
gion, but  it  may  occur  at  any  portion  of  tiie  lungs,  or  a  whole  lung 
becomes  infiltrated,  and  undergoes  the  cheesy  degeneration  (phthisis 
tlorida). 

As  in  croupous  pneumonia,  so  in  pneumonic  phthisis  is  there  in- 
volvement of  the  overlying  pleura  of  tubercular  character  in  the 
latter  disease.  Rarely  rupture  of  lung  and  pleural  structure  occur, 
causing  tubercular  pneumohydrothorax. 

Symptoms.  Pneumonic  phthisis  occurs  in  three  forms — the 
chronic,  the  subacute,  and  the  acute. 

Chronic  form.  The  origin  is  rather  insidious,  the  individual  being 
susceptible  to  "colds,"  or  "  catarrhs,"  on  the  slightest  exposure; 
gradually  a  persistent  cough,  with  the  expectoration  of  vucco-pus,  is 
established,  each  severe  cold  being  accompanied  with  chill, fever, 
pain  in  the  chest,  and  either  slight  hemorrhages  or  blood-streaked 
sputa.  Finally,  the  catarrhal  symptoms  become  persistent,  with 
morning  chills,  tv&nmg  fevers,  and  rather  profuse  night-sweats,  dis- 
tressing cough,  profuse  muco-purulent  sputa,  containing  the  bacilli, 
great  weakness  and  exhaustion,  loss  of  appetite  and  feeble  digestion, 
the  symptoms  growing  persistently  worse,  death  occurring  from 
exhaustion  after  one  or  two  years'  duration. 

Subacute  variety.  History  of  an  acute  attack  of  pneumonia  of  one 
or  two  weeks'  duration,  followed  by  a  decided  improvement,  but  not 
complete  recovery.  After  a  lapse  of  some  weeks  or  months  symp- 
toms of  pulmonary  softeninghtgm,  destroying  the  lung  structure  and 
forming  cavities,  accompanied  by  chills,  fever,  night-sweats,  emaci- 
ation, cough,  muco-purulent  2iX\d.blood-streahed expectoration  contain- 
ing the  bacilli,  the  patient  dying  from  exhaustion  within  a  year. 

Acute  variety,  the.  so-caiUed phthisis  ^orida,  runs  a  rapid  course, 
beginning  either  as  a  croupous  or  catarrhal  pneumonia,  involving 
the  whole  of  one  or  part  of  both  lungs,  associated  with  rapid  loss  of 
flesh  and  strength,  high  but  variable  temperature,  I03''-I05''  F.,  with 
remissions,  profuse  night-sweats,  shortness  of  breath,  severe  cough, 
profuse,  purulent,  and  blood-streaked  sputa  containing  the  bacilli,  loss 
of  appetite,  and  feeble  digestion,  the  patient  succumbing  in  a  few 
weeks  or  months  from  exhaustion. 

A  decided  remission  in  the  local  and  general  symptoms  of  the  acute 
variety  may  occur,  the  disease  afterward  pursuing  a  more  chronic 
course. 


DISEASES   OF   THE   LUNGS.  337 

Inspection.  Shows  deficient  respiratory  movements  of  the  dis- 
eased portion  of  the  lungs. 

Palpation.  Increased  vocal  fremitus  over  the  consolidated  lung 
tissue  and  cavities. 

Percussion.  The  percussion  note  varies  from  a  slight  impair- 
ment of  the  normal  note  at  either  ape5c  to  dullness,  and  when  cavities 
are  formed,  associated  with  scattered  points  of  the  tympanitic  or 
hollow  note.  If  the  cavities  communicate  with  a  bronchial  tube,  the 
cracked-pot  or  cracked-metal  sound  is  elicited.  If  the  cavities  are 
filled  with  pus,  the  percussion  note  is  dull.  If  the  pus  be  expelled, 
the  tympanitic  or  cracked-pot  sound  returns. 

Auscultation.  The  vesicular  murmur  is  unimpaired  in  those 
parts  free  from  disease;  it  isy^^(5/<?  or  indistinct  if  many  bronchioles 
are  obstructed ;  and  is  harsh  or  blowing  if  the  bronchioles  are  nar- 
rowed. The  inspiratory  sound  will  be  jerking,  and  the  expiratory 
sound  prolonged  and  blowing  when  the  lung  has  lost  its  elasticity. 

Associated  with  the  impaired  vesicular  murmur  is  a.  fine,  dry,  crack- 
ling sound  (crepitation),  appearing  at  the  end  of  inspiratioti.  If  bron- 
chitis be  associated,  large  and  small  moist  or  bubbling  rales  are  also 
heard  during  respiration. 

When  cavities  form,  either  bronchial  or  broncho-cavernous  respira- 
tion is  heard,  associated  with  more  or  less  d\?,\.\nct  gurgling  rales.  If 
the  cavity  be  free  from  pus  and  have  rather  firm  walls,  the  breathing 
is  more  amphoric  in  character. 

Diagnosis.  Catarrhal  bronchitis  has  many  points  of  resemblance 
to  pneumonic  phthisis.  The  subsequent  course  of  the  latter,  with  the 
high  temperature,  prostration,  emaciation,  sputa  containing  bacilli, 
and  physical  signs  will  prevent  error. 

Acute  fibrinous  and  catarrhal  pneumonia,  often  after  a  course  of 
two  or  three  weeks,  show  the  bacilli  and  yet  are  not  recognized  as 
tuberculosis.  It  is  a  safe  rule  of  practice  to  suspect  tuberculosis  and 
examine  daily  for  the  bacilli  in  all  cases  of  pneumonia  that  show  the 
least  tendency  to  linger,  and  particularly  where  there  are  chills  and 
a  remittent  temperature  record. 

Prog'nosis.  Acute  variety,  the  phthisis  florida,  usually  terminates 
fatally  within  a  few  months. 

The  subacute  and  chronic  varieties  may,  under  judicious  treatment 
and  favorable  hygienic  conditions,  be  arrested,  the  caseous  matter 
partly  expectorated  and  partly  absorbed,  leaving  more  or  less  loss  of 

22 


338  PRACTICE    OK    MEDICINE. 

Structure,  cicatricial  tissue    supplying  its  place,  which  after  a  time 
contracts,  causing  more  or  less  retraction  of  the  chest  walls. 

Cases  not  properly  treated,  either  from  carelessness  or  poverty, 
succumb  after  a  year  or  two. 


TUBERCULAR   PHTHISIS. 

Synonyms.  Tuberculosis;  consumption;  incipient  phthisis; 
chronic  phthisis  ;  chronic  ulcerative  phthisis. 

Definition.  A  chronic  pulmonary  disease  caused  by  the  bacillus 
tuberculosis,  resulting  in  the  deposition  of  tubercle  in  the  lung  structure, 
which  in  turn  undergoes  ulceration  and  softening  which  results  in  a 
septic  infection,  characterized  by  progressive  failure  of  health,  fever,, 
cough,  dyspnoea,  emaciation,  and  exhaustion. 

Causes.  Hereditary  and  acquired  susceptibility  to  the  influence 
of  the  bacillus  tuberculosis.  It  is  questionable  if  an  individual  is  born 
with  pulmonary  tuberculosis,  but  makes  his  advent  with  tissues  that 
are  a  congenial  soil  for  the  growth  and  ravages  of  this  wide-spread 
germ.  Amongst  the  acquired  causes  are  syphilis,  alcoholism,  chronic 
nephritis,  certain  occupations,  and  living  in  damp,  overcrowded, 
dark,  and  badly  ventilated  locations.  Debility  following  an  attack  of 
influenza  predisposes  to  the  deposition  of  tubercle. 

Pathological  Anatomy.  Tubercle  is  a  grayish-white,  translu- 
cent, and  semi-solid  granulation,  about  the  size  of  a  millet-seed,  most 
commonly  deposited  in  the  walls  of  the  bronchioles,  or  around  the 
small  blood-vessels, — a  peri-arteritis, — exciting  alow  form  of  inflam- 
mation, the  result  of  its  own  death.  The  masses  of  tubercle  soon 
undergo  softening  (cheesy  transformation) ;  the  lung  structure  is  sec- 
ondarily affected,  undergoing  softening,  which  results  in  more  or  less 
destruction  of  the  tissue,  whence  cavities  are  formed. 

The  inflammation  may  extend  to  the  small  arteries,  causing  hemor- 
rhage. 

The  deposit  of  tubercle  is  generally  at  one  of  the  apices,  and  "  once 
present  in  an  apex,  the  disease  usually  extends  in  time  to  the 
opposite  upper  lobe ;  but  not,  as  a  rule,  until  the  lower  lobe  of  the 
lung  first  affected  has  been  attacked.  Lesions  of  the  base  may  be 
primary,  though  this  is  rare."  Depositions  may  also  occur  in  the 
brain,  intestines,  and  liver. 


DISEASES   OF   THE   LUNGS.  339 

The  pleura  is  usually  the  seat  of  a  chronic  inflammation  (dry 
pleurisy,  tubercular),  resulting  in  the  obliteration  of  the  pleural  cavity. 

Symptoms.  The  symptoms  correspond  closely  to  the  stages  of 
deposition,  oi  softening,  septic  infection,  and  of  \ki&  formation  of  cavi- 
ties. 

The  development  is  insidious, w\\h  increasing  dyspepsia  and  anatnia, 
the  loss  of  appetite,  distress  after  meals,  and  feeling  of  weakness, 
often  misleading  the  patient  and  physician  for  some  time  until  the 
occurrence  of  an  irritable  heart,  3.  slight,  dry,  hacking  cough,  referred 
to  the  throat  or  stomach,  scanty,  glairy  expectoration,  gradual  loss  of 
weight,  impaired  muscular  strength,  pallid  appearance,  and  a  more 
or  less  copious  hcemoptysis.  Pain,  sharp  in  character,  below  the 
clavicles,  is  often  present.  These  symptoms  are  characteristic  of  the 
development  of  the  disease. 

The  beginning  of  softening  is  announced  by  increased  cough,  freer 
expectoration,  showing  under  the  microscope  the  bacilli,  dyspncea  in- 
creased on  exertion,  morning  chills,  cvtmng  fever,  night-sweats — the 
so-called  hectic  fever,  diarrhoea,  increased  ejnaciation  and  weakness, 
the  patient,  however,  continuing  very  hopeful. 

With  \hQ  formation  of  the  cavities  the  cough  is  more  aggravated, 
with  profuse  and  purulent  expectoration,  at  times  containing  yellow 
striae,  the  amount  depending  upon  the  number  and  size  of  the  cavi- 
ties ;  hemoptysis  is  not  common  at  this  stage  ;  the  pulse  rapid  and 
weak,  increased  hectic,  burning  of  the  soles  and  palms,  copious 
night-sweats,  greater  debility  and  emaciation,  with  oedema  of  the  feet 
and  ankles,  denoting  failure  of  the  circulation,  death  soon  following 
from  asthenia,  the  mind  clear  and  hopeful  to  the  end. 

Inspection.  First  stage,  often  shows  slight  depressions  in  the 
supra-clavicular,  and  at  times  in  the  infra-clavicular  regions. 

Palpation.  Second  stage,  the  vocal  fremitus  is  slightly  increased 
at  both  or  either  apex. 

Percussion.  First  stage,  slight  impairtnent  of  the  normal  per- 
cussion resonance  can  sometimes  be  elicited  at  both  or  either  apex. 
Second  stage,  the  resonance  is  impaired,  and  may  be  even  dull. 
Third  stage,  dullness  with  circumscribed  spots  of  the  amphoric,  or 
tympatiitic  or  cracked-pot  sound. 

Auscultation.  First  stage,  inspiration  jerky,  expiration  pro- 
longed, the  pitch  higher  than  normal,  the  inspiration  associated  with 
crackling  rales  at  both  or  either  apex. 


340  PRACTICE    OF    MEDICINE. 

Second  stage,  z/«ftfo-^r<7«r//w/ breathing,  associated  with  subcrepi- 
tant  and  large  and  moist  or  bubbling  rales. 

Third  stage,  bronchial,  broncho-cavernous,  and  cavernous  respira- 
tion, associated  with  large  and  small  moist  or  bubbling,  and  localized 
gurgling  rales. 

Bronchophony  in  its  various  degrees  is  associated  with  the  second 
and  third  stages  of  tuberculosis. 

Complications.  Tubercular  diseases  of  the  brain,  larynx,  i)leura, 
intestines,  and  peritoneum  ;  perineal  abscess  leading  to  fistula,  endo- 
carditis, and  myocarditis. 

Diagnosis.  The  early  diagnosis  of  tubercular  phthisis  rests  mainly 
on  the  history,  together  with  the  symptoms  and  physical  signs.  In 
the  first  stage  it  is  often  mistaken  for  dyspepsia,  anaemia,  malarial 
fever,  or  disease  of  the  heart ;  if  the  bacilli  can  be  found  in  the  sputum, 
the  diagnosis  is  settled. 

Prognosis.  In  the  main  unfavorable,  although  under  proper 
treatment,  change  of  climate,  and  like  favorable  conditions  life  may 
be  prolonged  for  years. 


FIBROID  PHTHISIS. 

Synonyms.  Chronic  interstitial  pneumonia ;  cirrhosis  of  the 
lungs ;  Corrigan's  disease. 

Definition.  A  hyperplasia  (thickening)  of  the  pulmonary  con- 
nective tissue,  resulting  in  atrophy  and  degeneration  of  the  vesicular 
structure,  associated  with  bronchial  inflammation  ;  characterized  by 
cough,  profuse  expectoration  containing  the  bacillus  tuberculosis, 
fever,  emaciation,  and  ultimately  death  by  asthenia. 

Causes.  Hereditary  predisposition  ;  inhalation  of  irritants  and 
associated  with  certain  occupations,  such  as  stone  cutting,  grinding, 
etc.  Following  lobar  pneumonia;  chronic  bronchitis;  alcoholism; 
syphilis;  chronic  nephritis. 

Pathological  Anatomy.  In  addition  to  the  pneumonic  changes 
in  the  lung  structure,  there  is  developed  a  reparative  or  fibrous  process 
resulting  in  thickening  of  the  bronchial  mucous  membrane  and  dila- 
tation of  the  air  tubes.  Hyperplasia  of  the  pulmonary  connective 
tissue,  resulting  in  the  compression  and  consequent  destruction  of  the 
vesicular  structure,  which  is  assisted  by  the  contraction  of  the  newly 


DISEASES   OF  THE   LUNGS.  341 

formed  tissues.  Sooner  or  later  catarrhal  pneumonia  results,  the 
product  undergoing  the  cheesy  degeneration,  cavities  being  formed, 
and  as  a  result  of  the  long-continued  suppuration,  tubercular  deposi- 
tions occur,  hastening  the  destruction  of  the  lung  tissue. 

Prof.  Da  Costa  has  reported  a  number  of  cases  of  "grinders' 
phthisis,"  in  whose  sputum  was  found  the  "bacillus  tuberculosis," 
and  in  whose  family  history  there  were  no  traces  of  consumption. 

Symptoms.  The  course  is  chronic,  beginning  as  a  bronchial 
catarrh,  worse  in  winter,  better  in  summer,  when,  after  several  years, 
the  cough  becomes  more  continiiotis,  the  expectoration  freer  and 
muco-purulent,  containing  the  bacilli  tuberculosis  in  large  numbers. 
Gradually  hectic  fever  develops,  with  night-sweats,  dyspncea,  and 
rapid  emaciation,  soon  followed  by  cedetna  of  the  feet  and  ankles,  the 
result  of  failing  circulation,  death  occurring  by  asthenia. 

Inspection.     Depression  of  the  chest  walls. 

Percussion.  Impaired  r&son^ince.,  followed  by  dullness,  with  ir- 
regular spots  of  amphoric  or  tympanitic  percussion  note  over  the 
points  of  depression. 

Auscultation.  First  stage,  vesiculo-bronchial,  or  harsh  respira- 
tion, associated  with  large  and  small  moist  or  bubbling,  rales,  followed 
by  bronchial,  broncho-cavernous,  and  cavernous  respiration,  with  cir- 
cumscribed gurgling  rales. 

Diagnosis.  Beginning  as  a  bronchial  catarrh,  slowly  progressing, 
with  the  remission  of  the  symptoms  during  the  summer  months, 
finally  becoming  progressively  worse,  the  discovery  of  the  bacilli  in 
the  sputum,  with  the  formation  of  cavities,  and  symptoms  of  asthenia, 
are  the  chief  points  in  the  diagnosis. 

Prognosis.  The  duration  of  fibroid  phthisis  is  most  protracted, 
six  to  twelve  years  being  the  average  duration  ;  death,  however,  is 
the  inevitable  termination. 

Prof.  Da  Costa  has  records  of  one  hundred  deaths  from  "  grinders' 
consumption  "  whose  average  life  was  twelve  years  from  the  develop- 
ment of  the  signs  of  the  disease. 

TREATMENT   OF    PULMONARY  TUBERCULOSIS. 

Can  pulmonary  tuberculosis  be  prevented  ?  To  a  great  extent, 
yes,  as  in  a  large  proportion  of  cases  the  infection  of  the  system  is 
the  result  of  contagion  or  the  ingestion  of  food  containing  the  germs 
in  those  having  the  inherited  or  acquired  phthisical  diathesis.     It  is 


342  PRACTICE    OF    MEDICINE. 

now  known  that  tuberculosis  is  very  common  in  the  cattle  whose 
flesh  forms  so  large  a  portion  of  the  food  of  man.  Were  it  not  for 
the  protection  given  by  cooking,  the  history  of  this  disease  would  be 
a  sadder  one  than  it  is.  But  the  milk  is  not  often  cooked.  May 
not  the  great  increase  in  tuberculosis  be  caused  by  the  use  of  cows' 
milk  ? 

The  bacilli  once  found  in  the  sputum,  can  the  unfortunate  host  be 
cured  ? 

While  I  have  never  seen  a  case  of  marked  incipient  phthisis  cured, 
in  the  broad  acceptation  of  the  term,  I  have  repeatedly  seen  life  pro- 
longed for  a  number  of  years,  and  the  deposition  of  tubercle  long 
delayed  by  a  change  of  climate  early  in  the  history  of  the  case,  warm 
clothing,  life  and  exercise  in  the  open  air  short  of  fatigue,  and  sys- 
tematic bathing  with  a  nutritious  plan  of  dieting.  If  the  diet  is  ar- 
ranged in  accordance  with  the  appetite,  the  latter  will  gradually 
increase,  but  should  it  not,  it  may  be  stimulated  by  such  bitters  as 
siryc/inuKE  sulphas,  mix  vomica,  ignatia  amara,  Colombo,  or  gentian. 

For  a  number  of  years  I  have  been  in  the  practice  of  placing  in- 
cipient cases  of  tuberculosis  upon  what  I  term  "  up  and  down  "  doses 
of  strychnines  sulphas,  and  often  with  a  success  that  is  amazing.  A 
formula  is  given  of — 

R.     Str}'chnin3e  sulph., gr.  iv  .26  Gm. 

Aq.  cblorofoimi,  vel 

Ess.  pepsini, f^^ij  60.     Cc.  M. 

SiG. — Ten  minims  equal  gr.  -^^  (0.0025  Gm.). 

Mode  of  using  :  Five  drops  three  times  daily  for  one  week,  then  ten  drops 
three  times  daily  for  a  week,  then  fifteen  drops  three  times  daily  for  a  week, 
then  twenty  drops  three  times  daily  for  a  week,  then  fifteen  drops,  then  ten 
drops,  then  five  drops,  and  so  on  week  after  week  for  months  and  years. 

The  symptoms  are  to  be  met  as  they  arise,  and  drugs  are  not  to  be 
used  simply  because  the  patient  has  the  physical  signs  of  beginning 
phthisis.  For  the  general  debility  and  malaise  that  accompanies  the 
early  stages  of  the  malady,  any  one  or  a  combination  of  the  follow- 
ing drugs,  exercising  care  that  they  in  no  way  interfere  with  the 
appetite  :  Guaiacol,  TTLiij-v  (0.2-0.3  Cc.)  for  adults,  and  trLij-iij  (0.12- 
0.2  Cc.)  for  children,  four  times  daily,  in  either  sweetened  water,  milk, 
or  meat  broth,  or  wine;  oleum  morrhuce,  ferri  iodidum,  hypophos- 


DISEASES   OF  THE   LUNGS.  343 

phiies,  strychnincB  arse?iias,  gr.  5*5—50  (0.001-0.002  Gm.)  after  meals,  or 
a  combination  oi  arsenicufii  and  digitalis  : 

R.     Acidi  arseniosi,       gr.  j  .065  Gm. 

Digitalini  (Merck's), gr.  j  .065  Gm.  M. 

Ft.  pil.  No.  XXX. 

SiG. — One  after  meals. 

For  the  cough  and  expectoration,  creosote,  n\^j  (0.06  Cc.)  in  milk, 
water,  or  whiskey  three  times  daily,  gradually  increasing  the  dose  a 
minim  a  day  until  stomach  toleration. 

In  the  pneumonic  variety  the  attempt  should  always  be  made  to 
remove  the  caseous  matter  by  absorption  and  expectoration.  The 
following  prescriptions  will  sometimes  prove  successful : 

R.     Ammonii  carb,, gr-   v  -3        Gm. 

Ammonii  iodidi, gr.   v— x  -S-.S  Gm. 

Aq.  chloroformi, f^ij  8.  Cc. 

Syr.  prun.  virg., f^ij  8'  ^c.  M. 

Every  five  hours,  diluted,  alternating  with 

Liq.  potassii  arsenitis, TTLv  .3  Cc. 

Mass.  ferri  carb., gr.  v  .3  Gm. 

Vini  xerici, f  ?j  4.     Cc. 

Aquas, q.   s.   ad  f5ss  15.     Cc.                M. 

In  the  tubercular  variety  the  early  ^^/^//zV  symptoms  are  wonder- 
fully relieved  by  the  following  : 

R.     Pepsini  cryst., gr- ij  .13  Gm. 

Acidi  hydrochlorici  dil.,    .    .    .    .    TT\^xv  I.       Cc. 

Glycerini,     ...  Tt\,xx  1. 3    Cc. 

Succi  limonis,       Tt\^xv  I.       Cc. 

Aquse  aurantii  flor.,    .    .    .    .     ad  f  3  ij  ad      8-       Cc.  M. 

SiG. — With  meals,  diluted. 

It  is  in  this  variety  of  consumption  that  every  means  should  be 
employed  to  improve  the  general  health.  Improvement  may  often 
follow  the  long- continued  moderate  use  of  alcoholic  stimulants,  the 
amount  being  only  such  as  will  increase  the  appetite  and  improve 
the  digestion.  If  rise  of  temperature,  flushed  face,  or  dyspeptic 
symptoms  occur,  discontinue  the  stimulants  at  once.  Be  sure  of  the 
diagnosis  before  resorting  to  alcohol. 

For  the  fibroid  variety,  to  prevent  the  hyperplasia  of  the  connective 
tissue,  hydrargyri  corrosivum  chloridujn,  potassii  iodidum,  or  aurii  et 
sodii  chloridum,  are  recommended.     Oleum  tnorrhucB  is  of  benefit. 


344  PRACTICE   OF    MEDICINE. 

For  ihe £'as/n'c  symptoms,  which  are  often  so  severe  as  to  seriously 
interfere  with  assimilation,  either  bismuthum,  gr.  xx  (1.3  Gm.)  before 
meals,  or  arsenicum  : 

B. .     I,ii]iior.  potassii  arsenitis,  .    .    .    TTLxxx  2.  Cc. 

Tinctuni;  nucis  vomicrc,     .    .    .  f^j  4.  Cc. 

Aqurechlorofomii,  .    .    .    .     ad  f  5  ij  ad        60.  Cc.  M. 

SiG. — Teaspoonful  before  meals,  diluted. 

For  the  fever,  unfortunately,  but  little  can  be  accomplished  with 
drugs.  If,  however,  it  exceeds  101°  F.,  an  attempt  should  be  made 
to  reduce  it. 

The  "  Niemeyer  pill  "  is  usually  recommended,  its  formula  being — 

li.     Quininxsulph., gr.  j  .065  Gm. 

Pulv.  digitalis, gr.  ss  .032  Gm. 

Pulv.  opii gr-  /^  -016  Gm. 

Pulv.  ipecac, gr-  X  -^'^  ^™- 

From  a  very  considerable  experience  with  this  "famous  "  pill,  I 
can  recall  few  cases  in  which  it  has  proven  of  the  least  benefit.  The 
following  is  much  more  effectual : 

li-     Quininrcsulph., gr-  x  .6  Gm. 

Quininre  muriat., gr.  x  ,6  Gm. 

Pulv.  opii  at  ipecac, gr.  iij  .2  Gm. 

Ft.  capsul.  No.  ij. 

Sin. — One  capsule  five  hours  and  the  other  three  hours  before  the  decided 
rise  of  temperature. 

In  a  few  instances  the  temperature  has  been  favorably  influenced 
by  antifebrin,  gr.  v  (0.3  Gm.),  in  tablets,  at  one,  three,  and  five 
o'clock  each  afternoon,  or  acetanilidton,  gr.  v  (0.3  Gm.),  at  the  same 
hours.  If  sweating  occur,  add  to  each  five-grain  tablet  agaricin, 
gr.  -^  (0.002  Cm.).  Many  patients  prefer  cool  sponging,  adding 
alcohol,  vinegar,  or  bay-rum  to  the  water,  and  there  is  no  doubt 
that  sponging  will  promptly  reduce  the  temperature  two  or  three 
degrees. 

For  the  cough  the  following  may  give  relief: 

R.    Codein?esulphat., g^.  y^-}4  .022-.032  Cm. 

Acidi  hydrocyanic!  dil., Ti\,ij  .12  Cc. 

Syr.  tolu, fgj  4-  Cc    M. 

SiG. — Several  times  a  day. 


DISEASES   OF   THE   LUNGS.  345 

Or— 

Bt.    Codeinse,      gr.  iv  .26  Gm. 

Acid,  hydrochlor.  dil., f^ss  2.  Cc. 

Spirit,  chloroformi f  ziss  6.  Cc. 

Syr.  limonis, f^^j  30.  Cc. 

Aq.  lauro-cerasi, ad  f^^iv  ad  120.  Cc.                M. 

SiG. — A  teaspoonful,  repeated  when  cough  is  troublesome. 

If  diarrhcea  develop,  bismut/mm,  gr.  xx-xxx  (1.3-2  Gm.)  every 
three  or  four  hours,  with  rest  in  bed  and  mustard  to  the  abdomen  ; 
or  B.  Cupri  sulphat.,  gr.  iss  (o.i  Gm.);  ext.  nucis  vomica,  gr.  iij 
(0.2  Gm.)  ;  pulv.  opii,  gr.  vj  (0.4  Gm.).  M.  et  ft.  pil.  No.  xij.  SiG. — 
One  every  three  or  four  hours  ;  or  B .  Liquor,  potassii  arsenitis,  Tr\^xxx 
(2  Cc.) ;  tincturse  opii  deodorat.,  f^iss  (6  Cc.) ;  liquor  pepsini,  ad 
f^ij  (60  Co.).     M.     SiG. — Teaspoonful  at  meal  time. 

For  night-sweats,  atropince  sulphas,  gr.  ^  (o.ooi  Gm.)  at  bed-time, 
or  agaricin,  gr.  ^'g-jj;  (0.003-0  006  Gm.)  at  bed-time,  adding  small 
doses  of  morphina  if  it  cause  loose  stools.  Camphoric  acid,  gr.  xx- 
xxx  (1.3-2  Gm.),  about  two  hours  before  the  expected  sweat,  the 
time  of  administration  is  important,  as  the  drug  is  rapidly  eliminated 
and  it  has  the  additional  advantage  of  causing  no  ill  or  disagreeable 
effect.  It  is  best  given  dry  on  the  tongue,  or  in  cachets.  It  is 
claimed  that  sulphonal,  gr.  v-x  (0.3-0.6  Gm.),  at  bed-time,  controls 
the  night-sweats  and  also  produces  a  quiet,  refreshing  sleep. 

For  hcBtnoptysis  no  one  remedy  is  comparable  with  atropiticB 
sulphas,  ^x.  •j^jj-j-^^p-g\j  (0.00032-0.00065-0.001  Gm.),  repeated  pro  re 
nata ;  or  nitro-glycerifium,  one  per  cent,  solution,  n^j  (0.06  Cc), 
every  fifteen  minutes  for  a  few  doses,  often  acts  promptly. 

Beginning  in  December,  1890,  a  large  number  of  cases  of  incipient 
tuberculosis  were  treated  in  the  wards  of  the  Philadelphia  Hospital 
with  Koch's  tuberculin.  The  treatment  was  negative  in  every  case. 
In  the  fall  of  1892  ten  cases  of  early  tuberculosis  were  placed  under 
treatment  with  Kleb's  tuberculocidin.  Its  action  is  different  from 
Koch's  tuberculin  in  that  it  never  excites  the  febrile  reaction  of  the 
latter.  The  results  were  also  negative,  although  for  several  months 
the  patients  seemed  free  from  the  bacillus. 

The  diet  must  be  of  the  most  nutritious  and  easily  digestible 
character.  If  oleum  morrhttcs  or  petrolatum  can  be  assimilated, 
either  should  be  used  for  a  long  time.  The  hygiene  of  the  patient  is 
of  the  utmost  importance,  and,  as  it  is  a  struggle  for  life,  no  means 
should  be  left  untried  to  gain  the  victory. 


3-lG  PRACTICE    OF    MF.DiriNK. 


DISEASES  OF  THE  PLEURA. 


PLEURITIS. 

S3rnonyms.     Pleurisy  ;  "stitch  in  the  side." 

Definition.  A  fibrinous  inflammation  of  the  pleura,  either  acute, 
subacute,  or  chronic  in  character,  occurring  either  idiopathically  or 
secondarily ;  characterized  by  a  sharp  pain  in  the  side,  a  dry  cough, 
dyspnoea,  and  fever.  It  may  be  hmited  to  a  part,  or  may  involve 
the  whole  of  one  or  both  pleural  membranes. 

Causes.  Idiopathic  pleuritis  is  said  to  be  due  to  cold  and  expo- 
sure, to  injuries  of  the  chest  walls,  or  the  result  of  muscular  exertion. 
Tuberculosis  is  the  cause  in  a  few  instances. 

Secondary  pleuritis  occurs  during  an  attack  of  pneumonia,  pericardi- 
tis, rheumatism,  variola,  scarlatina,  measles,  Bright's  disease,  tuber- 
culosis, or  puerperal  fever. 

Chronic  pleuritis  follows  an  acute  attack,  or  is  the  result  of  tuber- 
culosis, Bright's  disease,  cancer,  or  alcoholism. 

Pathological  Anatomy.  The  ordinary  course  pursued  by  an 
inflammation  of  a  serous  membrane  is  hypercemia  followed  by  exu- 
dation of  lymph,  the  effusion  of  fluid,  its  absorption,  and  the  adhesion 
of  the  membranes. 

The  first  or  dry  stage  of  pleuritis  is  a  hyperaemia  or  diffused  irreg- 
ular redness  of  the  membrane,  with  little  specks  of  exudation.  The 
second  stage  is  characterized  by  the  copious  exudation  of  lymph,  more 
or  less  completely  covering  the  membrane,  giving  it  a  dull,  cloudy, 
or  shaggy  appearance.  If  the  inflammation  ceases  at  this  point,  it  is 
termed  dry  pleuritis.  The  third,  or  stage  of  effusion,  is  characterized 
by  the  pouring  out  of  a  semi-fibrinous  liquid,  more  or  less  completely 
filling  and  distending  the  pleural  cavity,  and  floating  in  the  fluid  are 
fibrinous  flocculi,  blood,  and  epithelial  cells. 

Absorptio7i  of  the  fluid  and  more  or  less  of  the  exudative  lymph 
soon  occurs,  the  unabsorbed  portion  becoming  organized,  forming 
adhesions  which  obliterate  the  pleural  cavity. 

The  effusion,  if  on  the  right  side,  pushes  the  heart  farther  to  the 
left;  if  on  the  left  side,  the  heart  is  displaced  to  the  right,  the  impulse 


DISEASES   OF  THE   PLEURA.  347 

often  being  seen  to  the  right  of  the  sternum.     The  lungs  are  also 
compressed  and  displaced  upward  and  against  the  spinal  column, 
and,  on  removal  of  the  fluid,  expand  again,  except  in  cases  of  chronic 
pleuritis,  when  the  functional  activity  of  the  pulmonary  structure  is^ 
more  or  less  permanently  impaired. 

Chronic  pleuritis  results  when  the  fluid  is  not  absorbed  or  when  it  is 
effused  into  the  cavity  in  a  slow  and  insidious  manner.  The  mem- 
brane is  irregularly  thickened,  with  firm  adhesions,  fluid  being 
found  in  the  meshes;  depressions  of  the  thoracic  walls  also  occur. 
The  fluid  may  be  serum,  pus  {empyema),  or  pus  and  blood.  Open- 
ings may  form,  through  which  there  is  permanent  discharge,  either 
externally  (fistulous  empyema)  or  into  the  bronchi,  or,  rarely,  into  the 
bowels. 

Symptoms.  Actite  variety  :  Begins  with  a  chill,  followed  by  a 
sharp,  lancinating /az'«  (stitch)  near  the  nipple  or  in  the  axilla,  aggra- 
vated by  coughing  and  breathing,  associated  with  '^\^\.  tenderness  on 
pressure.  The  respirations  a.vQ  rapid  and  shallow,  30-35  per  minute  ; 
a  short,  dry,  hacking  cough  ;  xaoAerzle  fever ;  compressible  pulse,  90- 
120.  With  the  effusion  of  liquid  the  dyspnoea  becomes  aggravated, 
the  cough  more  distressing,  the  cardiac  action  embarrassed,  the  coun- 
tenance wearing  an  anxious  expression,  the  patient  usually  lying  on 
the  affected  side.  With  the  absorption  of  the  fluid  the  symptoms 
gradually  ameliorate,  convalescence  being  more  or  less  rapid. 

Subacute  variety :  Begins  insidiously  after  cold,  exposure,  and 
fatigue  in  those  enfeebled.  Patients  usually  complain  of  a  sense  of 
weariness,  shortness  of  breath,  aggravated  on  exertion,  evening  y^-z/^r, 
followed  by  night-sweats,  short  harassing  cough,  none  or  very  scanty 
sputum;  \h^  pulse  is  small,  feeble,  but  frequent,  100-120  beats  per 
minute.     The  characteristic  pain  in  the  side  is  usually  wanting. 

Chronic  variety  :  Irregular  chills,  fever,  night-sweats,  dyspnoea, 
palpitation,  embarrassed  circulation,  with  more  or  less  prostration. 

Inspection.  First  stage,  deficient  movement  of  the  affected  side, 
on  account  of  the  pain  induced  by  full  breathing. 

Second  stage,  bulging  or  fullness  of  the  affected  side,  with  oblitera- 
tion of  the  intercostal  spaces  and  displacement  of  the  cardiac  im- 
pulse. 

Palpation.  Second  stage,  vocal  fremitus  feeble  or  absent  over 
the  site  of  the  effusion,  exaggerated  above  the  site  of  the  fluid. 
^direly ,  fluctuation  may  be  obtained. 


348  PRACTICE    OF    MEDICINE. 

Percussion.     First  stage  ;  may  be  slightly  impaired. 

Second  stage  ;  dullness  or  even  flatness  over  the  site  of  the  effusion  ; 
tympanitic  percussion  note  above  the  fluid. 

Auscultation.  First  stage;  feeble  vesicular  nuirmur  over  the 
affected  side,  the  patient  breathing  superficially,  to  prevent  the  pain; 
Ti.  friction  sound,  slight  and  grating  or  creaking,  becoming  louder  as 
the  exudation  of  lymph  increases,  limited  usually  to  the  angle  of  the 
scapula  of  the  affected  side,  rarely  heard  over  the  entire  side,  accom- 
panies the  respiratory  movements. 

Second  stage ;  feeble  or  absent  vesicular  murmur  on  the  affected 
side,  depending  upon  partial  or  complete  compression  of  the  lungs 
by  the  fluid.  Above  the  fluid  puerile  breathing,  and  just  at  the  upper 
margin  of  the  fluid  a  friction  sound  may  be  heard. 

"Wx^  vocal  resonance  \s  i!i\\T\\x\\'sn&A.  or  absent  over  the  site  of  the 
fluid  and  markedly  increased  above,  agophony  being  present  at  the 
upper  margin  of  the  fluid. 

With  the  absorption  of  the  fluid  the  vesicular  murmur  gradually 
returns,  associated  with  a  moist  friction  sound. 

Diagnosis.  Acute  pneumonia  is  often  mistaken  for  the  effusion 
stage  of  pleurisy.  The  points  of  distinction  are:  in  pneumonia  there 
is  the  pronounced  chill,  high  fever,  and  characteristic  sputa,  bronchial 
breathing,  exaggerated  vocal  fremitus  and  resonance,  and  no  displace- 
ment of  the  heart,  the  reverse  occurring  in  pleurisy. 

Enlargement  of  the  liver  ma-Y  hQ  mistaken  for  pleurisy  with  effu- 
sion, the  chief  point  of  distinction  being  that,  in  enlargement  of  the 
liver,  the  superior  line  of  dullness  is  depressed  upon  full  inspiration, 
while  in  pleurisy  with  effusion  inspiration  does  not  modify  the  loca- 
tion of  the  dullness. 

Prog'nosis.  Idiopathic  pleurisy  usually  terminates  in  recovery 
within  three  weeks.  Pleurisy  the  result  of  constitutional  causes  has 
its  prognosis  modified  by  the  condition  with  which  it  is  associated. 
Empyema,  unless  the  result  of  a  diathesis,  terminates  favorably. 
Double  pleurisy  is  unfarwrable.  The  etiological  factor  of  tuberculosis 
must  always  be  borne  in  mind  in  making  a  prognosis  in  pleurisy, 
whether  acute  or  chronic. 

Treatment.  At  the  onset,  in  plethoric  patients,  wet  cups  over  the 
affected  side  ;  if  great  dyspnoea,  severe  pain,  and  high  arterial  tension, 
even  venesection,  and  in  anaemic  or  weak  persons,  dry  cups,  follow- 
ing the  use  of  either  wet  or   dry  cups  with   poultices   or  turpentine 


DISEASES  OF  THE   PLEURA.  349 

stupes.  The  severe  pain  is  promptly  relieved  by  the  hypodermic  in- 
jection of  morphincB  sulphas,  over  its  site,  repeated  as  indicated,  or 
the  frequent  use  of  small  doses  of  pulvis  ipecacuanhcB  et  opii. 

In  the  very  early  stages  of  pleurisy  the  disease  maybe  cut  short  by 
sodiisalicylas,  gr.  xv-xx  (1-1.3  Gm.),  well  diluted  every  three  or  four 
hours.  In  the  stage  of  effusion  excellent  results  follow  the  use  of  the 
salicylates. 

After  effusion  has  begun,  extractum  pilocarpi fiuidum,  n\,xv  (i  Cc), 
every  two  or  three  hours,  or  in  drachm  doses  every  other  day  for  a 
week  or  two,  after  which  twice  weekly  ;  or — 

B .     Pota'^sii  acetat., gr.  xxx  2.  Gm. 

Infus.  digitalis,  . fgij  8.  Cc.  M. 

Every  three  or  four  hours. 

Bowditch,  of  Boston,  for  years  has  advocated  early  aspiration  in 
pleural  effusion.  If  after  three  or  four  days  no  impression  is  made 
on  the  effusion  by  drugs,  aspiration  should  be  employed  and  table- 
spoonful  doses  oi  liquor  ferri  eiammonii  acetatis  {Basham's  mixture) 
administered  every  four  hours,  and  an  early  morning  dose  of  niag- 
nesii  sulphas,  ^ss-j  (15-30  Gm.)  well  diluted. 

The  effusion  of  pleuritis  is  rapidly  removed  by  the  method  of  treat- 
ment suggested  by  Prof.  Matthew  Hay,  of  Scotland,  consisting  in  the 
use  of  a  concentrated  solution  of  saline  cathartics  :  "  Order  the  patient 
to  take  nothing  after  the  evening  meal,  and  then  an  hour  or  so  before 
breakfast  the  salt  is  given  dissolved  in  as  little  water  as  possible. 
Usual  dose  from  Zn'-v]  (15-24  Gm.)  to  5J-ij  (30-60  Gm.)  magnesii sul- 
phatis  to  an  ounce  or  two  of  water,  no  fluids  to  be  used  after  the  dose ; 
this  usually  produces  from  four  to  eight  watery  stools,  without  pain  or 
discomfort,  and  also  acts  as  a  diuretic." 

The  essence  of  the  "  Hay  method  "  consists  in  getting  the  concen- 
trated solution  into  the  intestines  at  a  time  when  the  fluid  contents 
are  scanty. 

If  the  effusion  is  uninfluenced  by  the  above-named  means,  use 
potassiiiodidum,  gr.  xv(i  Gm.),  every  four  hours,  well  diluted,  with 
flying  blisters  over  the  affected  side,  or  tmguenttim  hydrargyri  in  the 
arm-pits,  groins,  and  over  the  site  of  the  effusion. 

In  double  pleuritic  effusion^  evacuate  the  fluid  at  once  with  the  aspi- 
rator, and  use  the  potassium  and  digitalis  mixture  mentioned  above. 

Chronic  pleurisy.     If  the  effusion  be  still  serous,  it  is  often  absorbed 


350  PRACTICE   OF    MEDICINE. 

by  the  internal  use  oi poiassii  ioduium,  alternating  with  " Basham's 
mixture,"  and  blisters,  the  secretions  being  watched.  If,  however, 
the  liquid  is  pus  {empyema),  the  aspirator  should  be  used  at  once,  the 
patient  placed  upon  " Basham's  mixture,"  stimulants,  and  quinina 
hydrochloras. 

Usually,  however,  within  a  very  few  days  after  aspiration,  another 
accumulation  of  pus  will  have  taken  place.  Should  this  occur,  the 
purulent  pleurisy  should  then  be  treated  as  an  abscess,  an  incision 
being  made  between  the  fifth  and  sixth  ribs,  the  pus  evacuated,  a 
drainage-tube  introduced,  and  an  antiseptic  dressing  applied.  If  the 
tendency  to  pus  secretion  still  remains,  the  pleural  cavity  must  be 
washed  out  with  an  antiseptic  solution,  the  constitutional  treatment 
being  continued. 

HYDROTHORAX. 

Synonym.     Dropsy  of  the  pleura. 

Definition.  The  effusion  of  fluid  into  the  pleural  cavities  (bilat- 
eral), the  result  of  a  general  dropsy  from  renal  or  cardiac  disease. 

Pathological  Anatomy.  More  or  less  clear  serous  fluid  in 
both  pleural  sacs,  compressing  the  lung.  No  signs  of  intlanimation 
are  present. 

Symptoms.  Following  dropsy  of  the  abdomen  occurs  dyspnoea, 
with  signs  of  deficient  blood  aeration,  both  lungs  being  compressed. 

Palpation,     Absent  vocal  fremitus  over  the  site  of  the  fluid. 

Percussion.     Dullness  over  the  site  of  the  fluid. 

Auscultation.    Absent  vesicular  murmur  over  the  site  of  the  fluid. 

Diagnosis.  Easily  determined  by  association  of  the  symptoms 
with  a  general  dropsy. 

Prognosis.  Controlled  by  the  cause  producing  the  general  dropsy. 

Treatment.  Depending  upon  the  condition  causing  the  dropsy. 
Dry  cups  over  the  chest  afford  relief.  If  the  symptoms  of  non- 
aeration  of  the  blood  are  severe,  the  fluid  should  be  at  once  evacuated 
with  the  aspirator. 

PNEUMOTHORAX. 

Synonyms.     Air  in  the  pleural  cavity  ;  hydropneumothorax. 
Definition.     The  accumulation  of  air  in  the  pleural  cavities,  with 
the  consequent    development  of  inflammation  of  the   membranes; 


DISEASES   OF  THE   PLEURA.  351 

characterized  by  sharp  pain,  followed  by  rapidly  developing  dyspnoea 
and  cough. 

Causes.  Generally  the  result  of  tuberculosis,  causing  perfora- 
tion of  the  pleura.  Perforation  may  take  place  from  the  pleura 
into  the  lung,  in  connection  with  empyema  or  abscess  of  the  chest 
wall.  Direct  perforation  from  without,  by  laceration  of  a  fractured 
rib  or  severe  contusion. 

Pathological  Anatomy.  The  gas  in  the  pleural  cavity  consists 
of  oxygen,  carbon  anhydride,  and  nitrogen  in  variable  proportions. 
It  may  fill  the  pleural  sac  completely,  compressing  the  lung,  or  is 
sometimes  limited  by  adhesions.  The  gas  tends  to  excite  inflamma- 
tion, the  resulting  effusion  being  either  serous  or  purulent. 

Symptoms.  Symptoms  of  pneumothorax,  the  result  of  perfora- 
tion, are  sudden  or  sharp  pain  in  the  side,  intense  dysp7iaea,  attended 
with  symptoms  of  collapse,  coldness  of  the  surface,  and  cold  sweats. 

The  above  symptoms,  in  many  instances,  follow  a  severe  or  violent 
paroxysm  of  coughing.  In  severe  cases  there  is  never  a  moment's 
cessation  of  the  acute  pain  and  distressing  dyspnoea,  causing  orthop- 
ncea  from  the  onset  until  death. 

Inspection.  Enlargement  of  the  affected  side,  the  intercostal 
spaces  being  widened  and  effaced  or  even  bulged  out  so  that  the 
surface  of  the  chest  is  smooth.  Respiratory  movements  of  the  affected 
side  are  diminished  or  absent. 

Percussion.  Immediately  after  the  rupture  the  percussion  note 
is  hyper-resonant,  or  even  tympanitic  or  amphoric  in  quality.  If  the 
amount  of  air  in  the  pleural  cavity  becomes  extreme,  there  is  dullness 
on  percussion,  associated  with  a  feeling  of  great  resistance  or  density. 
When  effusion  of  blood  occurs,  dullness  is  observed  over  the  lower 
part  of  the  chest,  hyper-resonant  or  tympanitic  percussion  note  over 
the  upper  portions  of  the  chest,  these  sounds  changing  as  the  patient 
changes  position. 

Auscultation.  The  normal  vesicular  murmur  may  be  diminished 
or  absent.  The  typical  amphoric  respiratory  sound  is  heard  when 
the  fistula  is  open,  usually  associated  with  a  metallic  echo. 

Metallic  tiftkling,  or  the  bell  sound,  is  sometimes  distinctly  pro- 
duced by  breathing,  coughing,  or  speaking,  after  the  development  of 
inflammation  of  the  pleura. 

The  vocal  resonance  may  be  diminished  or  absent,  or,  rarely,  it 
may  be  exaggerated,  with  a  distinct  metallic  echo. 


352  I'KACTICIC    OF    MEDICINE. 

After  the  development  of  inflammation  in  the  pleura,  suddenly 
shaking  the  patient  gives  rise  to  a  splashing  sensation,  the  succussion 
sound,  if  both  air  and  fluid  are  present  in  the  pleural  cavity. 

Prognosis.  When  occurring  as  the  result  of  tuberculosis,  the 
prognosis  is  extremely  unfavorable;  rarely,  the  fistulous  opening 
is  closed  by  inflammatory  action  ;  the  case  then  becomes  one  of 
chronic  pleurisy. 

Treatment.  At  once  a  hypodermic  injection  of  morphines  sul- 
phas, which  relieves  the  severe  pain  and  somewhat  modifies  the  dis- 
tressing dyspnoea,  followed  by  the  evacuation  of  the  fluid  and  air 
with  the  aspifalor. 

If  the  fistulous  opening  be  closed  by  inflammatory  action,  the  case 
resolves  itself  into  one  of  chronic  pleurisy,  the  treatment  indicated  for 
that  affection  plus  the  treatment  of  tuberculosis,  being  the  indication. 


DISEASES  OF  THE  CIRCULATORY 
SYSTEM. 


The  methods  employed  in  making  a  physical  examination  of  the 
heart  are  :  I.  Inspection.  II.  Palpation.  III.  Percussion.  YV .  Aus- 
cultation. 

Inspection  indicates  the  exact  point  of  the  cardiac  impulse,  and 
the  presence  or  absence  of  any  shnoxTndA.  pulsations  or  any  change  in 
the  form  of  \.\\q  prcccordiutn. 

Normally  the  impulse  is  visible  only  in  ihe/ifth  interspace,  midway 
between  the  left  nipple  and  the  left  border  of  the  sternum,  its  area 
covering  about  one  square  inch,  most  distinct  in  the  thin,  while  often 
barely  seen  in  the  very  fleshy  ;  often  displaced  downward  by  full  in- 
spiration and  elevated  by  complete  expiration. 

Disease  may  alter  \he  position  and  area  of  the  impulse. 

The  position  of  the  impulse  is  moved  to  the  right  by  left  pleuritic 
effusions  ;  downward  by  cardiac  hypertrophy  or  pulmonary  emphy- 
sema ;  upward  by  a  pericardial  effusion. 

The  area  of  the  impulse  is  changed  and  enlarged  by  pericardial 
adhesions,  cardiac  dilatation  or  hypertrophy. 


DISEASES   OF  THE   CIRCULATORY  SYSTEM.  353 

Palpation  confirms  the  observations  of  inspection,  and  also  deter- 
mines \.h.e  force ,  frequency ,  and  regularity  of  the  cardiac  impulse. 

The  force  of  the  i7nptclse  is  diminished  by  cardiac  dilatation,  fatty 
and  fibroid  degenerations  of  the  heart,  emphysema,  pericardial  effu- 
sion, and  adynamic  diseases. 

The  impulse  is  iitcreased  by  cardiac  hypertrophy,  during  the  first 
stage  of  endocarditis  and  pericarditis,  functional  cardiac  disturbances, 
and  sthenic  inflammations. 

Percussion  will  determine  the  boundaries  of  the  superficial  and 
deep  cardiac  space,  the  so-CdW&A  prcecordiutn.  It  is  essential  that  the 
upper,  lower,  and  two  lateral  boundaries  of  the  pericardial  region  be 
memorized,  to  wit :  superior  boundary,  the  upper  edge  of  the  third 
rib  ;  the  lower  boundary  is  a  horizontal  line  passing  through  the  fifth 
intercostal  space  ;  the  left  lateral  boundary  is  about  or  a  little  within 
a  vertical  line  passing  through  the  nipple,  the  linea  mammalis ;  and 
the  right  lateral  boundary  is  an  imaginary  vertical  line  situated  one- 
half  an  inch  to  the  right  of  the  sternum.  These  boundaries  vary  some- 
what in  health,  but  are  sufficiently  accurate  for  all  practical  purposes. 

The  superficial  cardiac  space  represents  that  portion  of  the  heart 
uncovered  with  lung  ;  it  is  triangular  in  form,  its  apex  being  the  junc- 
tion of  the  lower  border  of  the  left  third  rib  with  the  sternum,  its  area 
not  exceeding  two  inches  in  any  direction. 

The  superficial  space  is  increased  by  cardiac  hypertrophy,  dilata- 
tion, or  pericardial  effusion. 

Diminished  zX  the  end  of  full  inspiration  or  by  emphysema. 

The  deep  cardiac  space  re.'pr&stnt's,  that  portion  of  the  heart  covered 
by  lung,  and  extends  from  the  upper  border  of  the  third  rib  to  the 
lower  edge  of  the  fifth  interspace,  and  from  half  an  inch  to  the  right 
of  the  sternum  to  near  the  left  nipple. 

It  is  increased  by  hypertrophy  or  dilatation  of  the  heart,  left  pleuritic 
effusion,  and  apparently  increased  by  consolidation  of  the  anterior 
border  of  the  investing  lung. 

Auscultation  indicates  the  character  of  the  normal  cardiac 
sounds  and  the  point  at  which  they  are  heard  with  greatest  intensity, 
and  should  be  thoroughly  familiarized  if  abnormal  sounds  are  to  be 
fully  appreciated. 

The  ear  or  stethoscope  applied  to  the  praecordium  distinguishes  in 
health  two  sounds,  separated  by  a  momentary  silence — the  short 
pause,  and  the  second  sound  followed  by  an  interval  of  silence — the 
iong  pause. 
23 


354 


I'RACTICIi    OK    MEIMCINK. 


The  first  sound,  corresponding  to  the  contraction  of  the  heart — the 
systole — is  louder,  longer,  and  of  a  lower  pitch  and  a  more  booming 
quality  than  the  second  sound,  and  has  its  point  of  greatest  intensity 
at  the  cardiac  apex  or  a  little  to  the  left.  It  corresponds  closely  in 
time  to  the  pulsations  as  felt  in  the  carotid  or  radial  arteries. 

Tyji-JiftT^w^/j^wWi/ is  shorter,  weaker,  and  higher  in  pitch  than  the 
first  sound,  and  has  a  clicking  or  valvular  quality,  having  its  point  of 
greatest  intensity  at  the  second  right  costal  cartilage  and  a  little  above, 
and  corresponds  to  the  closure  of  the  aortic  and  pulmonary  valves. 
The  sound  made  by  the  closure  of  the  tricuspid  valves  is  best  isolated 
at  the  ensiform  cartilage  ;  the  sound  made  by  the  closure  of  the 
pulmonary  valves,  at  the  third  left  costal  cartilage. 

The  following  table,  giving  the  phenomena  and  time  of  normal 
cardiac  movements,  will  assist  in  recalling  the  physiology  of  the 
heart : 


Systole  of  the 
heart,     or 
ventricular 
systole. 


Action  of  Heart. 

Ventricles  contracting, 
auricles  dilating. 

Auriculo-ventiicular  valves 
(mitral  and  tricuspid)  sud- 
denly close  and  remain 
closed  during  the  whole 
time  of  the  first  sound. 

Semilunar  valves  (aortic 
and  pulmonary)  open; 
movement  or  locomotion  of 
heart  causing  the  impulse  or 
apex  beat. 

Blood  rushes  out  from  the 
ventricles  into  aorta  and 
pulmonary  artery,  and  di- 
lates these  vessels  and  their 
extensions  (arterial  system). 

Blood  flows  slowly  into 
the  auricles  from  the  vena 
cava  and  pulmonary  veins. 

The  pulse  felt  in  different 
arteries  from  one-thirtieth  to 
one-eighth  of  a  second  later 
than  impulse. 


Sound 

AND   PAL'SE. 


Time  in  Onh- 
tenths  of  thb 
Heart's  Beats. 


First     car- 
diac sound 
(systolic) 
dull  and 
prolonged. 


About  four- 
tenths  of  the 
heart's  beats, 
or  twenty- 
four-sixtieths 
of  a  second. 


DISEASES   OF  THE   CIRCULATORY  SYSTEM. 


355 


Diastole  of  the 
heart,     or 
ventricular 
diastole. 


Action  of  Heart. 

Ventricles  dilating  and  re- 
ceiving blood  from  auricles. 
Auricles  dilating  and  receiv- 
ing blood  from  veins. 

Auriculo- ventricular  valves 
(mitral  and  tricuspid)  open. 

Dilated  pulmonary  artery 
and  aorta  recoil  and  sud- 
denly close  the  semilunar 
valves  (aortic  and  pulmonic), 
which  remain  closed  during 
the  whole  of  the  second 
sound  and  the  interval  of 
silence. 

Ventricles  and  auricles 
still  continue  to  dilate — viz. , 
receive  blood.  Near  the 
close  of  this  period  the  auri- 
cleSjbeing  fully  dilated  (filled 
with  blood),  suddenly  con- 
tract and  complete  the  dila- 
tation of  the  ventricles. 


Time  in  One- 
Sound  TENTHS  of  the 

AND  Pause.    Heart's  Beats. 


Second 
cardiac 
sound 
(diastole) 
short  and 
sharp. 


Period  of 

silence   or 

rest. 


About  three- 
tenths  of  the 
heart's   beats, 
or  eighteen- 
sixtieths  of 
a  second. 


About  three- 
tenths  of  the 
heart's    beats, 
or  eighteen- 
sixlieths  of 
a  second. 


The  extent  of  surface  over  which  the  cardiac  sounds  are  heard 
varies,  according  to  the  size  of  the  heart  and  the  condition  of  the 
adjacent  organs  for  transmitting  sounds. 

The  cardiac  sounds  may  be  altered  in  intensity,  quality, pitch,  seat, 
and  rhythtn,  or  they  may  be  accompanied,  preceded,  or  followed  by 
adventitious  or  new  sounds,  the  so-called  endocardial  or  cardiac  mur- 
murs. 

The  intensity  is  increased  h-^  cardiac  hypertrophy,  irritabihty  of  the 
heart,  or  consohdation  of  adjacent  lung  structure. 

The  intensity  is  diminished  hy  cardiac  dilatation  or  degeneration, 
during  the  course  of  adynamic  fevers,  emphysematous  lung  over- 
lapping the  heart,  or  pericardial  effusion. 

The  quality  and  pitch  of  the  first  sound  may  be  sharp  or  short  and 
of  higher  pitch  when  the  ventricular  walls  are  thin,  or  have  under-' 
gone  beginning  fibroid  change,  the  valves  being  normal  ;  its  pitch 


856  PRACTICE   OF    MEDICINE. 

and  quality  are  also  raised  during  the  course  of  low  fevers.  The 
second  sound  becomes  duller  and  lower  in  pilch  when  the  elasticity 
of  the  aorta  is  diminished  or  the  aortic  valves  thickened.  Either  or 
both  sounds  have  a  more  or  less  metallic  quality  in  irritable  heart 
and  during  gaseous  distention  of  the  stomach. 

The  seat  of  greatest  intensity  of  the  cardiac  sounds  is  changed  by 
displacement  of  the  heart,  pleuritic  effusion,  pericardial  effusion,  and 
abdominal  tympanites. 

The  rhythm  is  often  interrupted  by  a  sudden  pause  or  silence,  the 
heart  missing  a  beat,  or  the  sounds  are  irregular,  confused,  and  tumul- 
tuous, the  result  of  organic  changes  in  the  cardiac  muscle,  valves, 
orifices,  or  vessels  ;  or  a  reduplication  of  one  or  both  sounds  of  the 
heart  may  occur. 

The  ad'c'entitious  cardiac  sounds  or  murmurs  are  of  two  kinds  :  those 
made  external  to  the  heart,  as  pericardial,  exocardial,  or  frictional 
murmurs,  and  those  made  within  the  cardiac  cavity,  endocardial 
murvmrs. 

Pericardial  murmurs,  or  friction  sounds,  are  made  by  the  rubbing 
upon  one  another  of  the  roughened  surfaces  of  the  pericardial  mem- 
brane during  the  early  stages  of  inflammation.  The  sounds  have  a 
rubbing,  creaking,  or  grating  character,  and  are  differentiated  from 
a  pleural  friction  sound  by  their  being  limited  to  the  praecordium, 
synchronous  with  every  sound  of  the  heart,  and  not  influenced  by 
respiration. 

They  are  distinguished  from  an  endocardial  murmur  by  their  super- 
ficial rubbing,  creaking,  or  grating  character,  and  by  not  being  trans- 
mitted beyond  the  limits  of  the  heart,  either  along  the  course  of  the 
vessels,  or  to  the  left  axilla  or  back. 

Endocardial  murmurs  are  of  two  kinds — to  wit :  organic  cind  func- 
tional. 

Functional  endocardial  or  blood  murmurs  are  the  result  of  changes 
in  the  normal  constituents  of  the  blood. 

Their  character  is  soft,  they  are  heard  most  distinctly  at  the  base  to 
the  left  of  the  sternum,  during  the  systole,  are  not  transmitted  beyond 
the  limits  of  the  heart,  either  to  the  left  axilla  or  the  back,  and  they 
are  associated  with  general  anaemia. 

Organic  endocardial  murmurs  are  produced  by  blood  currents  pur- 
suing either  a  nortnal  or  an  ab nor jnal  6\rQCXior\. 

In  health  there  are  two  direct  blood  currents  upon  each  side  of  the 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  357 

heart — to  wit :  the  current  from  the  left  auricle  to  the  left  ventricle,  the 
mitral  direct  current;  the  current  from  the  left  ventricle  to  the  aorta, 
the  aortic  direct  ciirrefit ;  the  current  from  the  right  auricle  to  the  right 
ventricle,  the  tricuspid  direct  current ;  and  the  current  from  the  right 
ventricle  to  the  pulmonary  artery,  xYvq  pulmonic  direct  current. 

When,  from  disease,  the  valves  are  not  properly  closed,  the  blood 
is  allowed  to  flow  back  against  the  direct  current,  producing  abnormal 
blood  currents — to  wit:  when  the  mitral  valve  is  incompetent,  the 
blood  flows  from  the  left  ventricle  back  into  the  left  auricle  during  the 
cardiac  systole,  producing  the  mitral  regurgitant  or  indirect  curre7it ; 
when  the  aortic  valves  are  incompetent,  the  blood  is  permitted  to 
flow  from  the  aorta  into  the  left  ventricle  during  the  cardiac  diastole, 
producing  the  aortic  regurgitant  or  indirect  current ;  when  the  tricus- 
pid valves  are  incompetent,  the  blood  flows  from  the  right  ventricle 
back  into  the  right  auricle  during  the  systole,  producing  the  tricus- 
pid regurgitant  or  indirect  current ;  when  the  pulmonary  valves  are 
incompetent,  the  blood  flows  from  the  pulmonary  artery  into  the  right 
ventricle,  producing  the  pulmonic  regurgitant  or  indirect  current. 

The  ?nitral  direct  current  occurs  during  the  contraction  of  the  left 
auricle,  or  just  before  the  first  sound  of  the  heart  and  immediately 
after  its  second  sound.  The  aortic  direct  curretit  is  produced  by  the 
contraction  of  the  left  ventricle,  and  occurs  with  the  first  sound  of  the 
heart.  The  tricuspid  direct  current  occurs  during  the  contraction  of 
the  right  auricle,  or  just  before  the  first  or  immediately  after  the 
second  sound.  The  pulmonic  direct  current  is  produced  by  the  con- 
traction of  the  right  ventricle,  occurring  during  the  first  cardiac  sound. 

The  mitral  direct  or  presystolic  jnurmur  occurs  before  the  first 
sound  of  the  heart  and  immediately  after  the  second  sound.  It  is 
caused  by  a  narrowing  of  the  mitral  orifice,  has  a  blubbering  quality, 
well  imitated  by  throwing  the  lips  into  vibration  by  the  breath,  of  a 
low  pitch,  and  it  has  its  seat  of  greatest  intensity  at  the  cardiac  apex, 
and  is  not  transmitted  to  the  left  axilla  or  to  the  base  of  the  heart. 

The  mitral  regurgitant  or  systolic  murmur  occurs  with  the  first 
sound  of  the  heart,  resulting  from  the  failure  of  the  mitral  valves  to 
close  the  mitral  orifice  during  the  systole,  in  consequence  of  which 
the  blood  flows  back,  or  regurgitates  into  the  left  auricle.  It  is  usually 
of  a  blowing  or  churning  character,  and  has  its  seat  of  greatest  in- 
tensity at  the  cardiac  apex,  being  well  transmitted  to  the  left  axilla 
and  inferior  angle  of  the  left  scapula. 


368  PRACTICE    OF    MEDICINE. 

The  aortic  direct  murmur  occurs  with  the  first  sound  of  the  heart 
It  is  caused  by  a  narrowing  of  the  aortic  orifice,  has  a  rough  or  creak- 
ing character,  is  of  high  pitch,  having  its  seat  of  greatest  intensity  in 
the  second  intercostal  space,  to  the  right  of  the  sternum,  and  is  well 
transmitted  over  the  carotid  artery. 

The  aortic  reomrgitant  murmur  occurs  with  the  second  sound  of  the 
heart,  and  is  caused  by  the  failure  of  the  aortic  valves  to  close  the 
aortic  orifice  during  the  diastole,  permitting  the  blood  to  flow  back 
or  regurgitate  into  the  left  ventricle.  It  is  usually  of  a  blowing  or 
churning  character  and  of  low  pitch,  having  its  seat  of  greatest  in- 
tensity over  the  base  of  the  heart,  and  is  well  transmitted  downward 
toward  or  below  the  cardiac  apex.  It  is  the  only  organic  murmur 
heard  in  the  left  side  of  the  heart  which  occurs  with  the  second 
sound  of  the  heart. 

The  tricuspid  direct  murmur  occurs  before  the  first  sound  of  the 
heart  and  immediately  after  the  second  sound.  It  is  caused  by  a  nar- 
rowing of  the  tricuspid  orifice,  has  a  blubbering  quality,  and  is  low 
in  pitch,  having  its  seat  of  greatest  intensity  near  the  ensiform  carti- 
lage.    This  murmur  is  exceedingly  rare. 

The  tricuspid  regurgitant  murmur  occurs  with  the  first  sound  of 
the  heart,  the  result  of  the  failure  of  the  tricuspid  valves  to  close  the 
tricuspid  orifice  during  the  systole,  thus  allowing  the  blood  to  flow 
back  or  regurgitate  into  the  right  auricle.  It  is  usually  of  a  blowing 
or  soft,  churning  character,  having  its  seat  of  greatest  intensity  at 
the  ensiform  cartilage.  This  murmer  is  also  very  infrequent,  and 
occurs  mostly  when  the  right  ventricle  is  considerably  dilated,  and 
without  the  existence  of  any  valvular  disease. 

The  pulmonic  direct  murmur  occurs  with  the  first  sound  of  the 
heart.  It  is  generally  connected  with  congenital  lesions.  It  occurs 
at  the  same  instant  that  the  aortic  direct  murmur  occurs,  and  is  dis- 
tinguished from  the  latter  by  its  not  being  transmitted  into  the  carotid 
artery,  whereas  the  aortic  direct  murmur  is  always  thus  transmitted. 

The  pulmonary  regurgitatit  murmur  occurs,  like  the  aortic  regurgi- 
tant murmur,  with  the  second  sound  of  the  heart.  This  murmur  is 
exceedingly  rare,  and  its  presence  is  only  positively  differentiated 
from  the  aortic  regurgitant  murmur  by  the  absence  of  aortic  lesions 
and  symptoms. 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  359 

ACUTE  PERICARDITIS. 

Definition.  An  acute  fibrinous  inflammation  of  the  pericardium  ; 
characterized  by  slight  fever,  pain,  prsecordial  distress,  and  disturbed 
cardiac  action  and  circulation. 

If  the  inflammation  be  limited  to  the  parietal  or  visceral  layer,  or 
to  a  part  of  either,  it  is  termed  partial  or  circn7>iscribed  pericarditis ; 
if  it  involve  the  whole  of  both  surfaces,  it  is  i^rsnt.^  general  ox  diffused 
pericarditis. 

The  inflammation  may  be  primary  or  secondary. 

Causes.  Primary  pericarditis  resulting  directly  from  cold  and 
exposure  or  injuries  is  rare. 

Secondary  pericarditis  follows,  or  is  associated  with,  rheumatism, 
influenza,  scarlatina,  variola,  puerperal  fever,  tuberculosis,  septicaemia, 
Bright's  disease,  gout,  scurvy,  and  diabetes. 

It  is  frequently  associated  with  pneumonia  and  pleuro-pneumonia, 
particularly  in  alcoholics. 

Pathological  Anatomy.  The  same  as  of  serous  membranes 
in  other  situations.  The  morbid  changes  may  be  seen  as  (i)  acute 
plastic  or  dry  pericarditis  (frequently  tubercular) ;  (2)  pericarditis 
with  effusion,  sero-fibrinous,  hemorrhagic,  or  purulent. 

Hyperczmia  of  the  membrane,  most  marked  on  the  visceral  layer, 
followed  by  the  exudation  of  lymph  scattered  in  irregular  patches, 
giving  it  a  rough  and  shaggy  appearance  {dry  pericarditis),  followed 
by  the  effusion  of  a  sero-fibrinous  fluid,  with  flocculi  floating  in  it, 
and  at  times  mixed  with  blood.     Rarely,  the  fluid  is  purulent. 

The  fluid  and  lymph  undergo  absorption  with  resulting  adhesions 
identical  with  those  described  under  pleurisy. 

Symptoms.  Acute  pericarditis  may  be  well  marked  and  still 
present  none  of  the  characteristic  subjective  symptoms.  It  usually 
begins  with  rigors,  fever  of  the  remittent  type,  frequently  nausea  and 
vomiting, prcecordial distress dLTidtendLtmess,  acute  shooimg pains,  in- 
creased by  breathing  and  coughing  ;  dry,  suppressed  cough  ;  increased 
cardiac  action,  and  sometimes  violent  palpitation.  An  attack  of  peri- 
carditis secondary  to  an  existing  disease  presents  no  marked  symp- 
toms other  than  those  mentioned  to  indicate  its  onset.  Attacks  of 
nausea  and  vomiting  occurring  during  the  course  of  rheumatism, 
pneumonia,  pleurisy,  and  nephritis  should  call  attention  to  the  heart. 
Duration  of  this  early  stage,  from  a  few  hours  to  a  day  or  two. 


360  PRACTICE    OF    MEDICINE. 

Effusion  stage  :  The  symptoms  of  this  stage  are  in  keeping  with  the 
amount  and  rapidity  of  the  effusion  :  pracordial  oppression,  tendency 
io  syncope  ;  dyspnaa,  sometimes  amounting  to  orthopncEa  ;  dysphagia, 
Aiccoug/t,  Ti:iusea.  and  To/ni/ing  ;  feeble,  irregular /«/.v^/  sometimes 
either  melancholia,  delirium,  or  acute  maniacal  excitement. 

Absorption  is  generally  rapid,  the  heart  remaining  "  irritable  "  for  a 
long  time  after.  If  instead  of  absorption  the  fluid  accumulates  and 
life  is  not  destroyed,  the  pericardial  sac  becomes  dilated,  chronic 
pericarditis  resulting. 

Inspection.  Early  stage,  excited  cardiac  action  is  evidenced  by 
the  impulse. 

Effusion  stage,  feeble,  undulatory,  or  absent  impulse ;  its  position 
displaced  upward,  or,  rarely,  downward ;  bulging  of  the  praecordium 
and  protruding  abdomen  if  effusion  be  large. 

Palpation.  Early  stage,  excited  or  tumultuous  impulse  ;  peri- 
Q.zxd^\-a\  friction  fremitus  rare. 

Effusion  stage,  feeble  or  absent  impulse,  and  if  present,  its  position 
is  changed. 

Percussion.     Early  stage,  normal. 

Effusion  stage,  cardiac  dullness,  enlarged  vertically  and  laterally, 
and,  if  considerable  fluid,  of  a  triangular  shape,  with  the  base  of  the 
triangle  on  a  line  with  the  sixth  or  seventh  rib,  extending  from  the 
right  of  the  sternum  to  the  left  of  the  left  nipple,  narrowing  as  it  pro- 
ceeds upward  to  the  second  rib,  or  above,  which  represents  the  apex 
of  the  triangle.  The  shape  of  the  dullness  is  sometimes  altered  by 
changing  the  position  of  the  patient. 

Auscultation.  jE'^r/j/j/ajcr,?,  excited  cardiac  action,  and  usually 
Sifriction  sound  {e\oca.rd'ia.l  murmur)  synchronous  with  cardiac  sounds 
and  uninfluenced  by  respiration,  but  often  increased  by  pressure  with 
the  stethoscope. 

Elusion  stage,  cardiac  sounds  feeble  and  deep-seated  at  the  cardiac 
apex,  becoming  louder  and  distinct  toward  the  cardiac  base.  The 
friction  sound  is  sometimes  heard  at  the  cardiac  base. 

If  adsorption  occur,  the  above  signs  gradually  give  place  to  the 
normal,  the  friction  sound  returning,  of  a  churning,  or  clicking,  or 
grating  character,  gradually  disappearing. 

Diagnosis.  Endocarditis  is  often  confounded  with  pericarditis, 
the  points  of  distinction  between  which  will  be  pointed  out  when  dis- 
cussing that  affection. 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  361 

Cardiac  hypertrophy  or  dilatation  is  sometimes  confounded  with 
pericardial  effusion  ;  the  differences  between  which  will  be  pointed 
out  when  discussing  those  affections. 

Hydropericardiufn  may  be  mistaken  for  pericardial  effusion ;  see 
that  affection. 

Prognosis.  Controlled  by  the  severity  of  the  inflammation, 
causes,  and  coexisting  affections.  There  is  no  doubt  but  that  peri- 
carditis with  slight  effusion  is  frequently  overlooked.  If  slight 
effusion,  favorable.  Death  has  quickly  occurred  when  a  large 
quantity  of  fluid  has  been  rapidly  effused,  the  patient  being  really 
drowned  in  his  own  fluid.  Adherent  pericardium  is  a  frequent 
sequela. 

Treatment.  Perfect  rest  in  bed  with  absolute  mental  quiet. 
Death  has  followed  neglect  of  this  precaution,  and  particularly  during 
the  stage  of  effusion. 

The  important  indications  for  treatment  are  to  limit  the  inflamma- 
tory action  and  quiet  the  heart  in  the  first  stage,  and  to  promote 
absorption  and  prevent  cardiac  failure  in  the  second  stage. 

Local  applications  in  the  early  stage  are  most  valuable  ;  for  vigor- 
ous patients,  the  application  o'i  leeches  ox  wet  cvps\o  the  praecordium, 
followed  by  the  application  of  ice  poultices  or  iced  compresses  ;  in  the 
feeble,  dry  cups  in  the  praecordium,  followed  by  poultices. 

For  the  gastro-intestinal  symptoms  calomel  is  indicated,  and  it  may 
have  a  beneficial  effect  on  the  inflammatory  action  : 

R .     Hydrargyri  chloridi  mitis,      .    .    gr.  ^  .022  Gm. 

Sodii  bicarbonat., gr-  ij  -IS    Gm. 

Sacchar.  lactis, gf-  ij  -13    Gm. 

Dry  on  tongue  every  two  hours  until  free  action. 

The  late  Dr.  Pepper  said  the  "  following  combination  is  often  very 
acceptable  "  : 

R .     Pulv.  digitalis, 

Mass.  hydrargyri,  .    .    .    ,     aa     gr.  x  aa     .6  Gm. 

Pulv.  opii, gr.  V  .3  Gm. 

Quininss  sulph., gr.  xxx  2.     Gm. 

Ft.  mass  et  div.  in  pil.  No.  xx. 

SiG. — One  pill  three  or  four  times  daily. 

In  young,  vigorous  patients,  early  in  the  disease  control  the  excited 
cardiac  action  by  small  doses  o'i  aconitum  or  verairutn  viride  ;  in  the 


362  PRACTICE    OF    MEDICINE. 

adult,  aged,  or  feeble  using  digitalis  ;  in  all  cases  quinina:  sulpltas  or 
hydrochloras  is  indicated.  Avoid  all  cardiac  sedatives  in  secondary 
cases  save  those  following  rheumatism. 

If  pain  is  severe  during  the  pre-effusion  stage,  fulvis  opii  et  ipe- 
cacuanha or  morphince  sulphas  may  be  cautiously  used. 

Effusion  stage  :  As  the  effusion  progresses,  the  free  administration 
of  alkalies — to  wit :  ainvionii carbonas,  gr.  v  (0.3  Gm.)  every  two  hours, 
with  liquor  ammonii  acetatis,  or  potassii  acetatis,  or  potassii  carbonatis, 
with  quinincr  sulphas  or  hydrochloras,  nutritious  liquid  diet  and  stimu' 
lants,  being  cautious  with  the  use  of  cardiac  sedatives  or  tonics. 

If  the  pericarditis  is  secondary,  the  general  treatment  of  such  con- 
dition must  be  continued. 

If  the  effusion  has  a  tendency  to  linger,  blisters  to  the  praecordium 
Tindi  potassii  iodidian  should  be  used,  and  if  the  symptoms  of  oppres- 
sion are  marked  or  the  effusion  linger,  paracentesis  is  indicated.  Dr. 
Roberts,  in  his  monograph,  gives  an  account  of  sixty  cases  of  para- 
centesis with  twenty-four  recoveries.  He  advises  that  the  tapping  be 
done  in  the  fossa  between  the  ensiform  and  costal  cartilages  on  the 
left  side,  or  in  the  fifth  left  interspace  near  the  junction  of  the  sixth 
rib  with  its  cartilage. 

Dr.  Tyson  recommends  the  use  of  a  blister  as  soon  as  the  diag- 
nosis is  determined.  He  says  :  "  There  is  no  other  disease  in  which 
I  am  so  satisfied  of  the  efficiency  of  a  blister;  it  helps  to  prevent 
effusion  and  also  to  promote  the  absorption  of  effusion." 

The  diet  must  be  nutritious  and  easy  of  digestion  throughout  the 
disease.  If  evidence  of  cardiac  failure,  use  strychnines  sulphas,  gr.  ^ 
(0.0025  Gm.),  hypodermically.  three  or  four  times  daily. 

CHRONIC  PERICARDITIS. 

Synonym.     Adhesive  pericarditis. 

Definition.  A  chronic  inflammation  of  the  pericardium,  with 
either  distention  of  the  sac  by  fluid  or  adhesions  of  the  pericardium 
(adherent  pericardium) ;  characterized  by  impaired  cardiac  action 
and  disturbances  of  the  circulation. 

Causes.  Almost  always  the  result  of  an  acute  attack.  The  line 
of  demarcation  between  the  acute  and  chronic  forms  is  not  sharp. 

Pathological  Anatomy.  If  the  effusion  be  absorbed,  the  peri- 
cardial surfaces  are  agglutinated  by  several  layers  of  lymph,  which 


DISEASES   OF  THE  CIRCULATORY  SYSTEM.  363 

increase  the  thickness  of  the  membranes  half  an  inch  or  more,  and 
the  outer  surface  of  the  pericardium  becomes  adherent  to  the  chest 
walls. 

If  the  fluid  is  not  absorbed,  it  may  progressively  accumulate,  dis- 
tending the  sac  in  all  directions,  displacing  the  diaphragm  and  inter- 
fering with  the  functions  of  the  surrounding  viscera,  or  a  low  grade 
of  inflammation  supervenes,  the  fluid  becoming  purulent  (empyema 
of  the  pericardium),  the  disease  terminating  fatally  after  a  variable 
period. 

As  much  as  eight  to  ten  pints  of  fluid  have  accumulated  in  the  sac. 

Symptoms.  Prcecordial  pain  and  distress  ;  \xx&gv\-3.x ,  feeble  car- 
diac action  ;  dyspncea,  aggravated  by  movement,  and  disturbed  circu- 
lation. 

An  agglutinated  pericardium  seriously  increases  the  danger  from 
an  attack  of  any  pulmonary  inflammation. 

Inspection.  If  the  effusion  be  present,  bulging  of  the  praecor- 
dium  and  displacement  of  the  impulse. 

If  adhesions  are  formed  between  the  pericardial  surfaces  as  well  as 
with  the  chest  walls,  inspection  reveals  depression  of  the  prcecordium, 
narrowing  of  the  spaces,  increased  extent  but  displaced  impulse,  un- 
influenced by  deep  inspiration,  and  recession  of  the  intercostal  spaces 
{systolic  dimpling)  and  epigastrium  with  every  systole  of  the  heart, 
the  result  of  the  adhesions. 

Palpation.  If  effusion,  displaced,  feeble,  or  absent  impulse  ;  if 
adhesions,  displaced  and  tumultuous  impulse ;  occasionally  a  peri- 
cardial fremitus  is  distinguished. 

Percussion.  If  effusion,  the  dullness  has  more  or  less  the  char- 
acter described  for  acute  pericarditis. 

If  adhesions,  the  cardiac  dullness  is  but  slightly  modified. 

Auscultation.  If  effusion,  cardiac  sounds  feeble  and  deep-seated 
at  the  apex,  louder  and  more  distinct  at  the  cardiac  base. 

If  adhesions,  cardiac  sounds  are  heard  with  equal  distinctness  in 
their  several  positions,  associated  with  a  rough  friction  sound  (exo- 
cardial  murmur). 

Treatment.  If  effusion,  blisters  to  the  praecordium,  with  potassii 
iodidutn  to  hasten  absorption,  the  patient  being  supported  by  nutritious 
diet,  quinines  sulphas,  ferrum  and  stimulants,  and  perfect  quiet.  If 
these  means  fail  to  remove  the  fluid,  or  if  the  fluid  be  purulent,  para- 
centesis should  be  performed  at  once. 


364  PRACTICE    OF    MKDICINE. 

If  adhesions  of  the  pericardium  have  resulted,  the  application  of 
blisters  to  the  priccordiuin,  with  the  administration  o{ potassii  iodidum, 
alternating  \\\\.\\ferru}n  and  quinina  hydrochloras,  are  indicated,  with 
nutritious  diet,  stimulants,  and  perfect  quiet. 


HYDRO-PERICARDIUM. 

Synonym.     Pericardial  dropsy. 

Definition.  The  accumulation  of  water  in  the  pericardial  sac, 
minus  inllammation  ;  characterized  by  praecordial  distress,  disturbed 
cardiac  action,  dyspnoea,  and  dysphagia. 

Causes.  Usually  a  part  of  a  general  dropsy  ;  Bright's  disease; 
sudden  pneumothorax  ;  pressure  of  an  aneurism  or  other  mediastinal 
tumor  ;    disease  or  thrombosis  of  the  cardiac  veins. 

Pathological  Anatomy.  The  fluid  may  range  in  quantity  from 
an  ounce  to  one  or  two  pints,  and  is  of  a  clear,  yellowish  or  straw- 
colored  serum,  at  times  turbid  or  bloody,  and  of  an  alkaline  reaction. 

If  the  amount  of  fluid  be  large,  the  sac  is  dilated,  its  walls  thinned 
by  the  pressure,  and  has  a  sodden  appearance. 

Symptoms.  Dropsy  of  the  pericardium  is  so  generally  associated 
with  hydrothorax  or  dropsy  of  the  pleurae  that  the  symptoms  are  but 
an  aggregation  of  those  attending  upon  that  condition — to  wit :  dis- 
tio'bed  cardiac  action,  dyspncea,  dysphagia,  dry  cough,  and  feeble  cir- 
culation. 

The  physical  signs  are  exactly  those  of  the  stage  of  effusion  of 
pericarditis,  minus  a  friction  sound. 

Diagnosis.  Pericarditis  with  effusion  and  hydro-pericardium 
present  nearly  the  same  signs  and  symptoms,  a  differentiation  being 
possible  only  by  a  history  of  the  case  and  the  symptoms  of  the  attack. 

Prognosis.     Controlled  entirely  by  the  cause. 

Treatment.  Depends  upon  the  cause  of  the  attack.  If  the 
amount  of  fluid  in  the  pericardial  sac  be  gTea.t,  paracentesis  will  give 
relief. 

ACUTE  ENDOCARDITIS. 

Synonyms.     Valvulitis;  exudative  endocarditis. 
Definition.     An  acute  fibrinous  inflammation  of  the  serous  mem- 
brane lining  the  cavity  of  the  heart  and  particularly  its  valves,  in 


DISEASES   OF   THE  CIRCULATORY   SYSTEM.  365 

severe  cases  the  chordae  tendineas  being  involved,  resulting  in  changes 
in  the  valves  or  orifices  of  the  heart,  or  both  ;  characterized  by  cough, 
dyspnoea,  disturbed  cardiac  action,  nausea,  vomiting,  and  more  or 
less  marked  febrile  reaction. 

Acute  endocarditis  occurs  in  two  distinct  forms  :  plastic  or  simple 
exudative  endocarditis  ;  ulcerous  or  diphtheritic  endocarditis. 

Causes.  Usually  secondary  to  acute  articular  rheumatism  (par- 
ticularly in  young  people),  pleuritis,  pneumonia,  pericarditis,  Bright's 
disease,  scarlatina,  influenza,  and  diphtheria.  Rarely  attacks  of 
endocarditis  are  due  to  a  gonorrhoea.  The  association  of  acute  endo- 
carditis and  chorea  is  frequent. 

While  as  yet  no  specific  micro-organism  has  been  discovered,  the 
view  is  gaining,  however,  that  it  is  a  microbic  affection. 

Pathological  Anatomy.  Inflammation  of  the  endocardium  is 
usually  limited  to  the  left  side  of  the  heart  after  birth,  during  foetal 
life  the  reverse  being  the  case.  The  inflammation  is  limited  or  espe- 
cially marked  at  the  valvular  portions  of  the  endocardium,  owing 
probably  to  the  presence  of  fibrous  tissue  beneath  the  membrane  in 
these  situations,  and  to  the  strain  which  falls  upon  the  valves  during 
the  performance  of  their  functions. 

Hyperamia  from  congestion  of  the  vessels  beneath  the  membrane, 
whh  considerable  swelling  of  the  valvelets,  the  result  of  an  exudation 
of  lymph  and  serum  beneath  and  on  the  free  surface  of  the  membrane 
covering  the  valves  and  chordce  tendinece,  resulting  in  the  roughening 
of  the  surfaces  and  the  agglutination  of  the  mitral  valves  to  each 
other,  and  of  the  aortic  segments  to  the  walls  of  the  aorta,  or  the  pro- 
liferation of  the  endocardial  connective  tissue,  forming  the  nuclei 
of  the  so-called  warty  excrescences  or  vegetations,  their  size  being 
increased  by  the  deposition  of  fibrin  from  the  blood  on  its  passage 
through  the  orifices. 

These  vegetations  may  be  detached  by  friction,  giving  rise  to  ejnboli, 
which  may  be  washed  by  the  blood  current  to  the  left  side  of  the 
brain,  or  into  the  kidneys  and  the  spleen. 

In  the  ulcerative  variety  a  process  of  softening  takes  place  in  the 
fibrinous  deposits,  leading  to  ulcerations  and  perforations. 

Symptoms.  The  affection  is  usually  masked  by  the  course  of 
another  disease  until  disturbances  of  the  circulation  direct  attention 
to  the  heart. 

The  onset  is  often  by  increase  of  temperature,  prcecordial  distress. 


366  PRACTICE    OF    MEDICINE. 

short  cough,  slight  dyspnaa,  more  or  less  persistent  vomiting  ;  increased 
cardiac  action,  often  rapid  and  tumultuous,  with  throbbing-  carotids 
and  noises  in  the  ear.  As  the  inflammation  progresses,  the  cardiac 
action  and  pulse  decline  in  frequency,  with  more  or  less  congestion 
of  the  hinj^s  and  venous  stasis. 

Auscultation.  Shows  a  change  in  the  character  of  the  sounds 
or  the  development  of  murmurs  at  the  various  orifices,  the  character 
and  points  of  distinction  between  which  will  be  pointed  out  when 
discussing  valvular  diseases  of  the  heart. 

Duration.     Between  one  and  three  weeks. 

Diagnosis.  Unless  it  is  a  rule  of  practice  to  always  auscult  the 
heart,  many  cases  will  pass  unobserved  or  undetected. 

Piricarditis  is  distinguished  from  endocarditis  by  the  character  of 
the  physical  signs.  In  pericarditis  the  murmur  or  friction  sound  is 
heard  with  either  cardiac  sound,  is  near  to  the  ear,  and  influenced  by 
pressure  of  the  stethoscope,  besides  being  associated  with  more  or 
less  alteration  in  the  size  and  shape  of  the  cardiac  dullness,  and  is 
not  transmitted,  while  in  endocarditis  the  murmur  takes  the  place  of 
or  is  associated  with  the  cardiac  sounds,  and  is  transmitted  to  points 
beyond  the  preecordia,  with  the  absence  of  change  in  size  and  form 
or  increased  dullness  on  percussion. 

If  embolism  occur,  a  new  set  of  symptoms  develop ;  embolism  of 
the  kidneys  causes  sudden,  deep-seated  lumbar  pain,  with  albumi- 
nuria and  even  ha^maturia ;  embolism  of  the  brain,  sudden  palsies  and 
sudden  disturbance  of  consciousness;  of  the  spleen,  sharp  pain  and 
tenderness  in  the  splenic  region  ;  of  the  skin,  petechial  or  purpuric 
spots. 

Prognosis.  Acute  endocarditis  is  not  very  dangerous  to  life, 
hence  a  favorable  prognosis  may  be  given  ;  regarding  the  ultimate 
results  of  valvular  lesions,  however,  the  prognosis  is  grave. 

Treatment.  Absolute  rest  in  bed.  At  the  onset  leeches  or  wet 
cups  to  the  pra^cordium,  followed  by  ice,  or,  what  may  be  preferable 
to  the  patient,  poultices. 

The  excited  circulation  should  be  controlled  hy  aconitu}n,z'eratrum 
viride,  or  digitalis,  each  of  these  drugs  having  their  particular  indi- 
cation. 

The  free  administration  of  such  alkalies  as  arnmonii  carbonas, 
poiassii  acetas  or  carbonas,  until  the  urine  is  decidedly  aikalme,  may 
prevent  permanent  changes  in  the  valves  or  orifices. 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  367 

If  alkalies  fail  and  the  inflammation  shows  a  tendency  to  linger, 
good  results  are  often  obtained  by  a  slight  hydrargyrum  impression. 

If  signs  of  oppressed  circulation  appear,  the  hands  becoming  blue, 
the  face  and  extremities  cedematous,  with  congestion  of  the  lungs, 
the  free  use  oi  ammonii  carbojias,  spiritus  a7nmonti  aromaticus,  nitro- 
glycerinum,  digitalis,  strophatithiis,  hypodermic  injections  oi  strych- 
nincB  sulphas,  and  stimulants  are  indicated.  No  drug  equals  atropinat 
sulphas  in  oedema  of  the  lungs,  no  matter  what  the  cause.  The  free 
use  of  amfnonit  carbonas  will  often  prevent  or  break  up  heart  clots. 
After  the  acute  symptoms  have  subsided,  more  or  less  absorption  of 
the  exuded  lymph  has  followed  the  free  use  oi  potassii  iodidum. 
During  the  entire  course  of  the  affection  the  diet  should  be  of  the 
most  nutritious  but  digestible  character. 


MALIGNANT  ENDOCARDITIS. 

Synonyms.  Ulcerative  endocarditis  ;  septic,  mycotic,  and  diph- 
theritic endocarditis. 

Definition.  An  acute  septic  inflammation  of  the  lining  mem- 
brane of  the  heart,  with  a  strong  tendency  to  ulceration  ;  characterized 
by  depression  of  the  vital  forces  with  more  or  less  cardiac  distress. 

Causes.  The  specific  micro-organism  has  not  yet  been  deter- 
mined. Frequently  complicates  pneumonia.  Associated  with  ery- 
sipelas and  septiceemia.  Rarely  associated  with  acute  rheumatism. 
Cases  have  been  reported  associated  with  or  following  influenza. 
Gonorrhoea  is  a  rare  cause. 

Pathological  Anatomy.  The  changes  are  those  of  acute  en- 
docarditis up  to  the  development  of  the  thickening  of  the  endocar- 
dium lining  the  valves,  and  the  development  of  the  vegetations. 
Instead  of  the  poison  spending  its  force  and  the  chronic  condition 
obtaining,  a  process  of  softening,  ulceration,  development  of  abscesses 
and  perforation  of  leaflets  follows,  resulting  in  loss  of  structure,  gen- 
eral septic  infection,  and  the  development  of  emboli,  which  lead  to 
infarctions,  with  their  results  in  either  brain,  kidney,  spleen,  eye,  or 
skin. 

Symptoms.  Vary  greatly,  but  always  associated  with  constitu- 
tional signs  of  sepsis — a  typhoid  state,  such  as  headache,  restlessness, 
varying  delirium  with  coated,  dry  tongue,  sordes  on  teeth  and  lips, 


368  PRACTICE    OK    MEDICINE. 

nausea,  vomiting,  loose  or  disordered  stools,  enlarged  spleen,  albumin 
in  urine,  and  an  irre^lar  temperature  record,  varying  from  ioo°  to 
104°  F.  or  higher,  associated  with  rii^ors  and  profuse  sweating. 

The  cardiac  action  is  rapid,  irregular,  and  weak — a  compressible 
pulse. 

In  the  notes  of  twelve  cases  observed  in  the  Philadelphia  Hospital 
are  the  following  symptoms  :  attacks  o{  prolonged  dyspna\i  with  par- 
oxysms of  intensity,  or  a  slightly  quickened  respiration  with  parox- 
ysms of  dyspncua  occurring  every  few  days  in  patients  with  hectic 
temperature  record.  In  four  cases  the  paroxysms  occurred  three 
limes  daily,  with  respirations  under  twenty-five  between  the  parox- 
ysms, for  three  weeks  preceding  death.  Usually  the  respirations  are  so 
oppressed  that  the  recumbent  position  is  impossible  for  long  periods. 
Another  frequent  symptom  is  marked  cyanosis,  either  transient  or 
lasting  for  days  before  the  end. 

A  frequent  symptom  of  ulcerative  endocarditis  is  a  peculiar yb^Afj, 
indicative  of  a  sense  of  impending  danger,  great  anxiety,  or  terror. 

If  embolism  occur,  there  are  superadded  symptoms  varying  with 
the  organ  affected.  If  the  brain,  rapidly  developing  palsies  with 
disorder  of  consciousness  ;  if  the  kidneys,  deep-seated  lumbar  pains 
with  hzematuria  or  disordered  urinary  flow  ;  if  the  spleen,  pain  and 
tenderness  of  the  splenic  region  with  increase  of  temperature  record. 

Auscultatiotl.  The  booming,  muscular,  first  sound  is  superseded 
by  a  feeble,  irregular  cardiac  pulsation.  Generally,  a  murmur  may 
be  detected. 

Diag'nosis.  One  of  the  most  difficult  in  medicine.  Remember- 
ing the  diseases  with  which  malignant  endocarditis  may  occur,  and 
particularly  pneumonia  or  sepsis,  and  the  dyspncea,  the  cyanosis,  the 
facies,  and  the  temperature  record,  it  may  be  possible  to  detect  the 
disease  much  more  frequently  than  formerly. 

Prognosis.     Unfavorable.     Recovery  the  rarest  termination. 

Treatment.  Entirely  symptomatic.  Nutritious  diet,  quinines 
sulphas,  fcrrum,  alcohol,  sttychnincB  sulphas,  strophanthus,  caffeina 
citratra,  and  digitalis.  For  the  cyanosis,  large,  frequently  repeated 
doses  of  nitro-glycerinum.  Local  application  seems  only  to  distress 
the  patient,  unless  it  be  an  emplastrum  belladonna. 


DISEASES   OF  THE   CIRCULATORY   SYSTEM.  369 

CHRONIC  ENDOCARDITIS. 

Synonyms.  Sclerotic  endocarditis;  interstitial  endocarditis; 
chronic  valvular  disease. 

Definition.  Alterations  in  the  cardiac  valves  or  orifices,  render- 
ing the  former  incapable  of  properly  closing  the  orifices,  or  causing 
the  narrowed  orifice  to  interrupt  the  blood  current  in  its  normal  move- 
ment. 

The  lesions  are  of  two  kinds  :  obstructive  and  regurgitant. 

An  obstructive  lesion,  termed  also  stenosis,  is  a  narrowing  of  the 
orifice,  thereby  obstructing  the  onward  passage  of  the  blood. 

A  regurgitant  lesion,  termed  also  ittsufficiency,  is  such  alteration  in 
the  valves  as  permits  a  portion  of  the  blood  to  flow  backward 
instead  of  onward,  the  true  direction  of  the  blood  current. 

Varieties.  I.  Mitral  regurgitation.  II.  Aortic  regurgitation.  III. 
Tricuspid  regurgitation.  IV.  Pulmonary  regurgitation.  V.  Mitral 
obstruction.  VI.  Aortic  obstruction.  VII.  Tricuspid  obstruction. 
VIII.  Pulmonic  obstruction. 

Causes.  The  great  majority  of  cases  are  the  result  of  an  attack 
of  acute  endocarditis  following  rheumatism,  chorea,  or  the  infectious 
diseases.  A  chronic  endocarditis  from  the  onset  may  be  caused  by 
alcoholism,  syphilis,  gout,  or  excessive  muscular  labor.  Chronic 
Bright's  diseases  are  also  exciting  causes.  • 

Professor  Da  Costa  has  clearly  established  the  development  of 
aortic  disease  in  early  life  by  overwork  and  strain  of  the  heart. 

In  the  elderly,  chronic  endocarditis  is  the  result  of  atheromatous  or 
fibroid  changes. 

MITRAL   REGURGITATION. 

This  form  of  valvular  disease  is  also  termed  mitral  insufficiency, 
and  is  the  most  frequent  variety  of  valvular  heart  disease. 

Pathological  Anatomy.  The  most  common  conditions  ob- 
served are  more  or  less  contraction  and  narrowing  of  the  tongues  of 
the  valves,  with  irregular  thickening  and  rigidity  ;  atheroma  or  calci- 
fication of  the  segments  ;  laceration  of  one  or  more  segments  ;  adhe- 
sion of  one  or  more  segments  to  the  inner  surface  of  the  ventricle ; 
thickened  and  stiffened  or  rupture  of  the  chordcs  tendinece,  and  also 
contraction  and  hardening  of  the  musculi  papillares. 

As  a  result  of  the  regurgitation  or  leakage  of  the  blood  back  into 
24 


370  PRACTICE    OF    MEDICINE. 

the  left  auricle,  there  is  a  dilatation  of  the  auricle,  foUowecl  by  slight 
cardiac  hypertrophy.  Ventricular  hypertrophy  occurs  after  a  time 
from  the  increased  number  of  the  cardiac  contraction?. 

Symptoms.  Insufficiency  of  the  mitral  valves  soon  leads  to  car- 
diac hypertrophy,  to  compensate  for  the  diminished  amount  of  blood 
sent  onward  by  the  ventricular  systole.  This  condition  causes 
quickened  and  strong  pulse  with  some  shortness  of  breath  on  severe 
exertion.  When  the  "  compensation  ruptures,"  there  occurs  pracor- 
dial  distress,  cough,  dyspnoea ;  feeble,  soft,  rapid,  irregular  pulse; 
finally,  from  weakened  cardiac  action,  may  result  pulmonary  conges- 
tion, with  cedematous  limbs  and  general  cyanosis,  the  abdominal 
cavity  filled,  liver  congested,  urine  scanty  and  albuminous,  the  patient 
dying  "  drowned  in  his  own  fluid." 

Inspection.  Cardiac  impulse  (apex-beat)  displaced  to  the  left 
and  downward.  In  children  and  youths,  bulging  of  the  prcecordia 
and  increased  cardiac  impulse. 

Palpation.  Displaced  cardiac  impulse,  early  stage  being  forcible 
and  diffused  ;  as  compensation  fails,  impulse  feeble  or  absent. 

Percussion.     Transverse  and  vertical  cardie  dullness  increased. 

Auscultation.  Systolic  blowing  or  churning  murmur,  audible  in 
the  mitral  area,  propagated  to  the  apex,  left  axilla,  and  under  the 
angle  of  the  scapula,  either  occurring  with  or  taking  the  place  of  the 
first  sottnd  of  the^  heart,  the  second  sound  being  markedly  accen- 
tuated. 

Prognosis.  So  long  as  the  compensating  hypertrophy  can  be 
maintained, the  prognosis  is  not  unfavorable;  when  dilatation  super- 
venes, however,  the  patient  soon  perishes,  either  from  congestion  of 
the  lungs  or  dropsy  and  exhaustion. 

AORTIC    REGURGITATION, 

Termed  also  aortic  insufficiency,  occurs  next  in  frequency  to  mitral 
insufficiency. 

Pathological  Anatomy.  The  valves  or  segments  adhere  to  the 
walls  of  the  aorta,  or  a  segment  is  lacerated  or  may  be  perforated,  or, 
more  commonly,  the  segments  are  shrunken,  deformed,  and  rigid, 
permitting  the  regurgitation  of  the  blood.  These  deficiencies  in  the 
valves  are  usually  associated  with  more  or  less  dilatation  of  the 
orifices. 

The  inability  of  the  aortic  valves  to  completely  close  the  aortic 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  371 

orifice  at  the  proper  moment  allows  the  blood  that  should  go  onward 
to  flow  back  into  the  left  ventricle,  and  the  normal  flow  of  blood  from 
the  left  auricle  continuing,  causes  overfilling  of  the  ventricle,  which 
results  in  a  dilatation  of  its  cavity,  and  the  extra  effort  of  the  ventricle 
to  empty  itself  results  in  hypertrophy  of  the  walls.  In  no  other  con- 
dition does  the  dilatation  and  hypertrophy  of  the  cardiac  walls  reach 
such  a  degree.  The  older  writers  named  this  enormous  enlargement 
of  the  heart  "  cor  bovinum." 

Symptoras.  There  are  no  characteristic  symptoms  so  long  as 
the  insufficiency  is  compensated  by  just  enough  hypertrophy  of  the 
ventricular  walls,  but  as  the  muscular  growth  increases,  the  symptoms 
are  those  of  marked  cardiac  hypertrophy — to  wit :  forcible  cardiac 
action,  headache,  tinnitus  aurium,  congestion  of  the  face  and  eyes, 
with  pulsating  vessels,  even  small  ones  pulsating  that  before  were  not 
visible  to  the  eye ;  pulsations  of  the  retinal  vessels  can  be  recognized 
with  the  ophthalmoscope ;  the  receding  pulse,  which  is  particularly 
characteristic — forcible  impulse  but  rapidly  declining,  called  "  water- 
hammer  "  pulse  and  also  the  "  Corrigan  pulse." 

As  soon  as  there  is  the  slightest  failure  in  the  compensation,  the 
cardiac  action  becomes  excessive  and  distressing  with  palpitation, 
causing  anxiety  and  fear  upon  the  part  of  the  patient. 

When  "compensation  ruptures,"  dyspnoea,  increased  on  exertion, 
cough,  cyanosis,  hepatic  enlargement,  congestion  of  the  kidneys,  with 
scanty,  albuminous  urine,  ascites,  and  dropsy  develop  either  gradually 
or  rapidly,  calling  for  prompt  medication.  If  mitral  insufficiency  is 
now  superadded,  general  venous  stasis  and  death  rapidly  occur. 

Praecordial  pain  is  usually  present  in  aortic  disease.  It  may  be  a 
sensation  of  constriction  in  the  cardiac  region,  or  sharp,  shooting 
pains  extending  to  the  arms — anginoidal  attacks. 

Inspection.     Forcible  cardiac  impulse. 

Palpation.     Strong,  full  cardiac  impulse. 

Percussion.  Cardiac  dullness  increasing  transversely  and  verti- 
cally. 

Auscultation.  First  sound,  forcible  ;  second  sound,  replaced  or 
associated  with  a  churning,  rushing,  or  blowing  murmur  of  low  pitch, 
distinct  at  the  second  right  costal  cartilage,  but  most  distinct  at  the 
junction  of  the  sternum  and  the  fourth  left  costal  cartilage,  trans- 
mitted downward  toward  and  below  the  apex. 

Prognosis.     The  one  valvular  disease  most  likely  to  occasion 


372  PRACTICE    OF    MEDICINE. 

sudden  death  ;  still,  so  long  as  the  compensating  hypertrophy  remains 
intact,  compatible  with  quite  an  active  life. 

TRICUSPID    REGURGITATION. 

Pathological  Anatomy.  This  form  of  valvular  insufficiency 
is  either  associated  with  right-sided  cardiac  dilatation  from  pulmonary 
obstruction,  or  is  the  result  of  mitral  disease. 

The  tricuspid  orifice  is  dilated  in  the  majority  of  cases  ;  occasion- 
ally the  segments  of  the  valves  are  contracted  or  adherent  to  the 
ventricle. 

Symptoms.  Venous  stasis  with  its  various  consequences,  and 
especially  pulsation  of  the  jugulars,  synchronous  with  the  cardiac 
movement,  and,  finally,  general  venous  pulsation,  especially  of  the 
liver,  pulmonary  congestion,  engorgement  of  the  kidneys,  and  dropsy. 
These  symptoms  are  superadded  to  those  of  the  affections  with  which 
tricuspid  insufficiency  is  always  associated. 

Inspection.  Diffused,  wavy,  cardiac  impulse  ;  jugular  pulsation 
synchronous  with  the  cardiac  movement,  uninfluenced  by  respiration, 
also  more  or  less  prominent  hepatic  pulsation. 

Palpation.     The  cardiac  impulse  extended,  but  feeble. 

Percussion.  Dullness  on  percussion,  extending  to  the  right  and 
below  the  sternum. 

Auscultation.  The  first  sound  is  accompanied  by  a  blowing 
murmur  most  intense  at  the  junction  of  the  fourth  and  fifth  ribs  with 
the  sternum,  distinct  over  the  xiphoid  appendix,  becoming  feeble  or 
lost  in  the  left  axillary  region  ;  often  associated,  however,  with  a 
mitral  systolic  murmur. 

PULMONIC   REGURGITATION. 

Pathological  Anatomy.  Insufficiency  of  the  pulmonary  valves 
is  of  rare  occurrence,  but  when  present,  the  changes  correspond  more 
or  less  with  those  described  for  aortic  regurgitation. 

Symptoms.  Those  of  dilatation  of  the  right  side  of  the  heart 
and  consequent  pulmonary  congestion — to  wit :  dyspnoea,  deficient 
aeration  of  the  blood  and  cyanosis,  distention  of  the  superficial  ves- 
sels, palpitation  of  the  heart,  precordial  distress,  sudden  suffocative 
attacks,  and  dropsy. 

Percussion.  The  cardiac  dullness  extending  to  the  right  of  the 
sternum. 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  3/3 

Auscultation.  A  loud,  blowing  murmur  associated  with  the 
second  sound  of  the  heart,  most  distinct  at  the  junction  of  the  third 
left  costal  cartilage  and  the  sternum. 

Prognosis.  Death  results,  sooner  or  later,  from  dropsy  and 
exhaustion. 

MITRAL   OBSTRUCTION. 

Mitral  obstruction  or  stenosis  is  not  so  frequent  as  regurgitation, 
and  is  very  often  associated  with  the  latter. 

Pathological  Anatomy.  Mitral  stenosis  is  caused  by  deposits 
around  the  orifice,  the  result  of  endocarditis,  or  else  the  segments  of 
the  valves  are  "glued  together  by  their  margins,"  leaving  but  a 
funnel-shaped  opening,  the  so-called  "  buttonhole  "  mitral  valve. 
Vegetations  on  the  valves  lead  to  more  or  less  obstruction  to  the 
blood-current. 

Symptoms.  Hypertrophy  of  the  left  auricle  results  from  obstruc- 
tion at  the  mitral  orifice,  followed  in  time  by  dilatation,  the  symptoms 
of  stenosis  being  unobservable  until  the  "  compensation  ruptures," 
or  until  dilatation  becomes  excessive,  when  occur  irregular,  small, 
zxv^  feeble puhe,  dyspnosa,  cotigh,  bronchorrhoea  the  result  of  bronchial 
congestion ;  dilatation  of  the  right  side  of  the  heart,  soon  leading  to 
general  venous  stasis,  dropsy,  and  death. 

Inspection.  Normal  until  auricular  hypertrophy,  when  an  undu- 
latory  impulse  is  observed  over  the  left  auricle. 

Palpation.  When  cardiac  dilatation  occurs,  a  diffused,  feeble, 
and  irregular  cardiac  impulse  is  felt  near  the  xiphoid  appendix. 

Auscultation.  First  sound  normal  in  character,  but  often  irreg- 
ular in  rhythm.  The  second  sound  normal.  A  blowing,  sometimes 
rasping,  sound  is  heard,  immediately  after  the  second  sound  of  the 
lieart  ceases,  and  immediately  before  the  first  sound  begins — a  pre- 
systolic murjnur,  heard  most  distinctly  in  the  mitral  area,  lessening  in 
intensity  toward  the  cardiac  base.  The  cardiac  sounds  are  all  more 
or  less  enfeebled  if  cardiac  dilatation  occur. 

Prognosis.  The  prognosis  is  controlled  by  the  duration  of  the 
hypertrophy.  Under  favorable  circumstances,  mitral  stenosis  is 
compatible  with  a  long  and  rather  active  life. 

AORTIC   OBSTRUCTION. 

Pathological  Anatomy.  Stenosis  of  the  aortic  orifice  is  caused 
by  the  projection  of  the  valves  inward,  and  their  becoming  rigid 


374  PRACTICE   OF    MEDICINE. 

and  thickened,  or  atheromatous  or  calcareous,  so  that  they  cannot  be 
pressed  back  by  the  blood,  but  remain  constantly  in  the  current  of 
the  circulation.  Occasionally  the  valves  are  covered  with  fibrinous 
masses,  the  opening  into  the  artery  being  thus  more  or  less  com- 
pletely closed,  or  the  segments  may  be  adherent  by  their  lateral 
surfaces,  leaving  a  central  opening,  which  may  be  so  contracted  as  to 
permit  the  passage  of  only  the  smallest  probe. 

Aortic  stenosis  is  nearly  always  a  disease  of  advanced  life,  and  is 
associated  with  the  arterial  changes  of  age.  Aortic  disease  is  not 
neaily  so  often  of  rheumatic  origin  as  mitral  diseases. 

Symptoms.  Hypertrophy  of  the  left  ventricle  rapidly  super- 
venes upon  aortic  stenosis,  and  so  long  as  the  cardiac  hypertrophy  is 
just  sufficient  for  compensation,  there  will  be  no  subjective  symptoms, 
many  cases  of  stenosis  being  discovered  when  the  individual  is  ex- 
amined for  insurance  or  other  reasons.  T\\t  pulse  is  s?iiail,  slow,  and 
hard.  When,  however,  the  compensatory  hypertrophy  begins  to  fail, 
the  supply  of  blood  to  the  brain  is  insufficient  in  many  cases,  and 
pallor,  with  attacks  of  7>ertigo,  syncope,  or  slight  epileptiform  seizures 
occur;  finally,  as  dilatation  of  the  left  ventricle  and  incompetence 
of  the  mitral  valve  result,  there  occur  pulmonary  congestion, 
dyspnoea,  and  general  venous  stasis,  the  pulse  soft  and  feeble. 

Palpation.  Lowered  cardiac  impulse,  strong  in  the  early  stage, 
feeble  when  dilatation  occurs. 

Percussion.  The  cardiac  dullness  is  increased  vertically,  the 
transverse  dullness  being  but  slightly  increased. 

Auscultation.  The  first  sound  of  the  heart  is  replaced  or  asso- 
ciated with  a  harsh,  rasping  sound,  whistling  at  times,  having  its 
greatest  intensity  at  the  junction  of  the  second  right  costal  cartilage 
with  the  sternum,  transmitted  along  the  vessels ;  the  murmur  may 
sometimes  be  heard  a  short  distance  from  the  patient. 

Usually,  aortic  stenosis  is  associated  with  more  or  less  aortic  regur- 
gitation, whence  a  double  miirviur  occurs,  having  its  greatest  intensity 
at  the  base  of  the  heart,  the  so-called  to  and  fro,  or  see-saw  murmur. 

Prognosis.  So  long  as  compensation  is  maintained  the  condi- 
tion of  the  patient  is  comfortable,  if  a  quiet  life  be  followed.  When 
the  compensation  is  ruptured,  the  usual  symptoms  of  dilatation, 
venous  stasis,  and  dropsy  soon  ensue. 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  375 

TRICUSPID   OBSTRUCTION. 

This  condition  is  one  of  the  rarest  affections  of  the  heart,  and  if  it 
ever  does  occur  with  or  following  an  attack  of  endocarditis,  the 
anatomical  changes  are  similar  to  those  of  mitral  obstruction.  This 
condition  soon  leads  to  auricular  dilatation  ;  venous  stasis  rapidly 
supervenes,  associated  with  venous  pulsations  similar  to  those  de- 
scribed when  speaking  of  tricuspid  regurgitation. 

PULMONIC   OBSTRUCTION. 

Pathological  Anatomy.  Always  a  congenital  malady,  the 
changes  consisting  in  "  constriction  of  the  pulmonary  artery,  un- 
closed foramen  ovale,  unclosed  ductus  Botalli,  stricture  at  the  ductus 
Botalli,  with  hypertrophy  of  the  right  cavity  and  frequent  association 
with  tuberculosis  of  the  lungs." 

Hypertrophy  of  the  right  ventricle  may  ensue,  the  walls  becoming 
almost  as  thick  as  those  upon  the  left  side. 

Those  in  whom  these  congenital  defects  in  the  cardiac  structure 
occur  are  otherwise  weak,  develop  slowly,  have  flabby  tissues,  soft 
bones,  and  seem  poorly  nourished. 

Symptoms.  The  hypertrophy  which  often  ensues  may  keep  life 
apparently  comfortable  for  some  time,  but  sooner  or  later  "  compen- 
sation ruptures,"  when  cough,  dyspnoea,  cyanosis,  and  death  occur. 

Prognosis.  The  duration  of  these  congenital  affections  is  short, 
usually  from  a  few  days  to  a  few  months ;  although  several  well- 
authenticated  cases  record  a  much  longer  duration. 

DIAGNOSIS   OF  VALVULAR   DISEASES. 

In  making  a  differential  diagnosis  between  the  various  forms  of 
valvular  disease  of  the  heart,  strict  attention  must  be  paid  to  the 
points  of  greatest  intensity  at  which  the  several  murmurs  are  heard. 

A  rmirmur  occurring  with  or  taking  the  place  of  the yirsi  sound  of 
the  heart — the  ventricular  systole — heard  most  distinctly  at  the  apex, 
transmitted  to  the  left  axilla,  and  to  the  inferior  angle  of  the  scapula, 
signifies  mitral  regurgitation — a  mitral  systolic  niuntiur. 

A  murmur  occurring  with  or  taking  the  place  of  ihejirst  sound  of 
the  heart,  with  its  point  of  greatest  intensity  at  the  xiphoid  appendix, 
signifies  regurgitation  at  the  tricuspid  orifice — a  tricuspid  systolic 
murmur. 


376  PRACTICE    OF    MEDICINE. 

A  murmur  heard  with  the  Jirsi  sound  of  the  heart,  high-pitched, 
rasping  or  grating  in  character,  with  its  point  of  intensity  greatest  at 
the  second  right  costal  cartilage,  signifies  obstruction  at  the  aortic 
orifice — an  aortic  systolic  murmur. 

A  murmur  heard  with  \.\v^  first  sound  of  the  heart,  soft  in  character, 
with  its  point  of  intensity  most  distinct  at  the  junction  of  the  third 
left  costal  cartilage  with  the  sternum,  signifies  obstruction  at  the  pul- 
monic orifice — a  pulmonic  systolic  murmur. 

A  murmur  occurring  immediately  after  the  second  sound  of  the 
heart,  and  immediately  before  the  beginning  of  the  first  sound  of  the 
heart,  signifies  obstruction  at  the  mitral  orifice — a  presystolic  tnitrat 
tnurmur. 

A  murmur  heard  with  or  taking  the  place  of  the  second  sound  oi 
the  heart,  most  distinct  at  the  second  costal  cartilage,  to  the  right  of 
the  sternum,  and  well  transmitted  toward  the  apex  or  below,  signifies 
insufficiency  or  regurgitation  at  the  aortic  orifice — an  aortic  regurgi- 
tant or  diastolic  murmur. 

Although  eight  distinct  valvular  murmurs  have  been  described  as 
occurring  in  the  heart,  those  on  the  right  side  are  of  rare  occurrence, 
and  hence  of  little  clinical  importance. 

If  a  fnurmur  be  heard  with  Xhe,  first  sound  of  the  heart,  it  is  almost 
certainly  aortic  obstructive  or  mitral  regurgitant ;  and  if  heard  with 
the  second  sound,  it  is  probably  aortic  regurgitant.  A  presystolic 
mitral  murmur  is  also  of  comparatively  rare  occurrence,  the  force 
with  which  the  blood  passes  from  the  left  auricle  into  the  left  ventricle 
being,  under  ordinary  circumstances,  insufficient  to  excite  sonorous 
vibrations. 

Functional  or  anamic  murmurs  may  be  confounded  with  the  va- 
rious forms  of  valvular  disease  of  the  heart.  The  chief  points  of  dis- 
tinction between  them  are,  that  an  anaemic  murmur,  which  is  always 
heard  at  the  base  of  the  heart,  is  always  systolic  in  time,  not  trans- 
mitted away  from  the  heart,  and  is  soft  in  character,  low  in  pitch,  and 
of  variable  intensity,  now  being  heard,  now  entirely  absent. 

Treatment.  There  is  no  special  plan  of  treatment  for  each  form  of 
valvular  disease.  Prof.  J.  M.  Da  Costa  says  :  "  I  hold  that  the  precise 
valve  affected  is  not,  with  our  present  resources,  the  keynote  to  the 
treatment  of  valvular  heart  disease.  We  are  to  take  as  indications: 
I.  The  state  of  the  heart-muscle  and  of  the  cavities.  2.  The  rhythm 
of  the  heart  action.     3.  The  condition  of  the  arteries  and  veins  and 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  377 

of  the  capillary  system.  4.  The  probable  length  of  existence  of  the 
malady  and  its  likely  cause.  5.  The  general  health.  6.  The  second- 
ary results  of  the  cardiac  affection." 

A  good  rule  in  practice  is  that  if  the  apex-beat  is  not  displaced,  the 
cardiac  dullness  is  not  increased  to  the  right  of  the  sternum,  and  dysp- 
noea is  absent,  medication  is  not  indicated  and  even  may  be  injurious. 

The  important  point  to  bear  in  mind  in  the  treatment  of  valvular 
disease  of  the  heart  is  that  it  is  associated  either  with  cardiac  hyper- 
trophy or  dilatation,  and  the  treatment,  if  any  at  all  be  required,  is 
directed  toward  this  secondary  condition.  If  compensation  be  com- 
plete, attention  to  the  condition  of  the  bowels,  kidneys,  and  digestion, 
with  some  general  directions  as  to  exercise,  are  all  that  is  required. 

If  the  hypertrophy  become  excessive,  it  is  best  controlled  by  either 
acoftittini,  veratrinn  viride,  or  spiritus  glonoini. 

If  dilatation  have  occurred,  the  heart's  action  weak  and  feeble,  the 
circulation  impeded,  and  venous  stasis  has  followed,  digitalis,  caffeines 
citrata,  strophanihus,  or  sparteines  sulphas,  with  more  or  less  active 
purgation,  is  indicated. 

If  fatty  degeneration  of  the  heart  result,  the  indications  are  for  car- 
diac rest,  strychnines  sulphas,  stimulants,  strophanthus,  or  spiritus 
glonoini,  and  attention  to  the  excretions. 

If  the  cardiac  rhythm  is  disturbed,  add  belladonna  or  lithii  bromi- 
dum  to  whatever  other  plan  of  treatment  is  being  used. 

If  the  capillary  circulation  is  weak,  strophanthus  and  nitro-glycer- 
z««7?z(glonoinum)  act  better  than  digitalis,  which  latter  has  the  power 
of  contracting  the  arterioles. 

Any  of  the  secondary  results  of  the  valvular  affection  are  to  be 
treated  according  to  the  particular  indications. 


CARDIAC  HYPERTROPHY. 

Definition.  An  overgrowth  or  increase  in  the  muscular  tissue 
which  forms  the  walls  of  the  heart ;  characterized  by  forcible  impulse, 
over-fullness  of  the  arteries,  diminished  blood  in  the  veins,  and  accel- 
erated circulation. 

Causes.  Obstruction  to  the  outflow  of  blood,  resulting  from 
valvular  disease  of  the  heart ;  emphysema  ;  Bright's  disease  ;  arterio- 
fibrosis ;  functional  over-action  ;  excessive  use  of  tobacco,  tea,  coffee, 
or  excessive  muscular  action. 


378  PRACTICE    OF    MEDICINE. 

Varieties.  I.  Simple  hypertrophy,  or  a  simple  increase  in  the 
thickness  of  the  cardiac  wails  ;  II.  Eccentric  hypertrophy ,'\v\zxt2i%^ 
in  the  cardiac  walls  and  dilatation  of  the  cavities,  causing  a  dilated 
hypertrophy ;  III.  Concentric  hypertrophy,  increase  in  the  cardiac 
walls  with  decrease  of  the  cavities,  a  very  rare  form. 

Patholog^ical  Anatomy.  Hypertrophy  of  the  heart  is  usually 
limited  to  the  left  side,  the  ventricles  more  commonly  than  the  auri- 
cles, the  latter  dilating. 

The  shape  of  the  heart  is  altered  by  hypertrophy  ;  if  the  right  ven- 
tricle, the  heart  is  widened  transversely  and  the  apex  blunted  ;  if  the 
left  ventricle,  the  heart  is  elongated  and,  as  a  rule,  the  cavity  is 
dilated  ;  if  both  ventricles  are  hypertrophied,  the  heart  has  a  globular 
shape.  From  increase  in  weight  the  heart  may  sink  lower  during  the 
recumbent  position,  thereby  lessening  the  area  of  cardiac  dullness, 
but  during  the  sitting  or  upright  posture  it  sinks  lower  in  the  chest 
and  to  the  left,  causing  more  or  less  prominence  of  the  abdomen. 

The  increase  in  the  size  of  the  organ  is  a  true  increase  or  hyper- 
trophy of  the  muscular  tissue,  and  not  a  hyperplasia.  The  tissue  is 
firmer  and  the  color  brighter  and  fresher  than  when  the  size  of  the 
organ  is  normal. 

The  cor  bo^nnum  of  the  old  writers  is  an  enormous  hypertrophy  of 
the  heart  with  dilatation  of  its  cavities. 

Symptoms.  Depend  upon  the  amount  of  hypertrophy.  The 
most  common  are  increased  and  forcible  cardiac  actioti,  the  arteries 
becoming  fuller,  the  veins  less  full,  and  the  circulation  accelerated ;  pul- 
sating carotids  and  aorta,  headache,  often  vertigo,  frequent  epistaxis, 
congestion  of  the  face  and  eyes,  tinnitus  auriuin,  dyspncea  on  exertion, 
dry  cough,  restless  nights,  with  more  or  less  jerking  of  the  limbs  ;  oc- 
casional praecordial  pains  shooting  toward  the  left  axilla;  full,  firm, 
bounding  pulse,  and  pulsations  in  the  superficial  arteries. 

A  sphygmographic  tracing  shows  the  line  of  ascent  vertical  and 
abrupt,  but  the  apex  is  rounded,  and  the  line  of  descent  is  oblique, 
unless  there  is  more  or  less  insufficiency  of  the  valves. 

Inspection.  Often  fullness  or  prominence  of  the  praecordium, 
with  distinct  impulse. 

Palpation.  The  impulse  is  felt  one  or  two  intercostal  spaces  lower 
down  and  to  the  left,  and  is  stronger  and  more  or  less  diffused — the 
heaving  impulse. 

Percussion.     The  area  of  cardiac  dullness  is  increased  vertically 


DISEASES   OF  THE   CIRCULATORY   SYSTEM.  379 

and  transversely  upon  the  left  side  of  the  sternum,  unless  the  right 
ventricle  is  also  hypertrophied,  when  the  cardiac  dullness  is  increased 
to  the  right  of  the  sternum. 

Auscultation.  If  simple  hypertrophy  without  any  coexisting 
changes  in  the  valves  or  orifices,  the  first  sound  has  a  loud  and  some- 
what metallic  quality,  the  second  sound  being  strongly  accentuated. 

Sequelae.  Cerebral  hemorrhage;  miliary  cerebral  aneurisms; 
dilatation  of  the  heart ;  fatty  changes  in  the  cardiac  tissue. 

Diagnosis.  Hypertrophy  of  the  heart  can  scarcely  be  mistaken 
for  any  other  disease  if  a  careful  study  of  the  physical  signs  be  made. 

Prognosis.  When  the  result  of  valvular  disease,  the  hyper- 
trophy is  said  to  be  compensatory.  If  the  result  of  Bright's  disease, 
emphysema  of  the  lung,  or  if  occurring  late  in  life,  or  associated  with 
atheromatous  degeneration  of  the  vessels,  the  prognosis  is  unfavorable. 
When  the  result  of  functional  over-action  in  the  strong  and  robust,  a 
further  enlargement  can  often  be  prevented  by  active  and  persistent 
treatment. 

Treatment.  The  indications  are,  if  the  hypertrophy  be  exces- 
sive, to  lessen  the  force  and  number  of  the  cardiac  pulsations  and  to 
remove  the  cause  whenever  possible. 

The  former  indications  are  best  met  by  the  persistent  use  of  tinctura 
acofiiti'vsx  small  doses,  Tt\,j-ij  (0.06-0.12  Cc),  three  times  a  day,  or  //;zr- 
tura  veratri  viridis,  Tt\,j-ij  (0.06-0.12  Cc),  three  times  a  day,  and  at 
the  same  time  keeping  the  bowels,  kidneys,  and  the  skin  acting  freely. 
A  certain  amount  of  hypertrophy  is  beneficial  in  chronic  valvular 
disease,  and  drugs  should  not  be  administered  simply  because  a  car- 
diac murmur  is  discovered  on  auscultation. 

The  habits  of  the  patient  are  to  be  corrected,  all  laborious  or  active 
exercise  to  be  restricted,  the  patient  to  be  in  the  recumbent  posture 
several  hours  during  the  day  if  possible,  the  diet  being  restricted, 
avoiding  all  forms  of  stimulants,  such  as  liquors,  tobacco,  tea,  and 
coffee. 

Cases  of  cardiac  hypertrophy  associated  with  Bright's  disease  are 
often  relieved  by  digitalis,  the  cardiac  distress  being  secondary  to  the 
kidney  disease,  for  which  the  digitalis  is  used. 

There  is  no  doubt  that  in  rare  instances  cardiac  pain  follows  the 
use  of  digitalis,  which  is  probably  due  to  the  firm  and  powerful  car- 
diac contractions  produced  by  digitalis ;  such  cases  do  better  with 
caffeines  citrata  or  strophanthus. 


380  PRACTICE    OF    MEDICINE. 

Cases  of  cardiac  hypertrophy  associated  with  anaemia  should,  in 
addition  to  digitalis  and  rest,  be  placed  upon  a  course  oi/t-rrum. 


DILATATION  OF  THE  HEART. 

Definition.  An  increase  in  the  size  of  one  or  more  of  the  cavities 
of  the  heart,  characterized  by  feebleness  of  the  circulation,  terminat- 
ing in  venous  stasis,  cyanosis,  oedema,  and  exhaustion. 

Causes.  Over-exertion  in  those  of  feel^le  resisting  powers,  as 
youths  or  soldiers,  as  first  pointed  out  by  Prof.  Da  Costa;  chronic 
valvular  disease;  emphysema;  chronic  bronchitis;  gout;  Bright's 
disease  ;  alcoholism  ;  syphilis. 

Varieties.  I.  Simple  dilatation,  the  cavities  being  enlarged,  the 
walls  normal.  II.  Active  dilatation,  corresponding  to  eccentric 
hypertrophy  ;  the  cavities  being  enlarged  and  the  walls  increased  in 
thickness,  the  so-called  "  dilated  hypertrophy."  III.  Passive  dilata- 
tion, the  cavities  being  enlarged  and  the  walls  thinned  or  stretched. 

Pathological  Anatomy.  The  right  side  of  the  heart  is  far 
more  frequently  involved  than  the  left  side.  The  shape  of  the  organ 
is  altered,  depending  on  the  part  affected.  The  weight  of  the  organ 
is,  as  a  rule,  increased,  as  hypertrophy  almost  always  accompanies  or 
precedes  dilatation. 

The  muscular  tissue  is  generally  pale,  mottled,  and  softened,  and 
under  the  microscope  presents  evidences  of  degeneration.  The  orifices 
also  participate,  and  especially  the  auriculo-ventricul.ir  orifice,  result- 
ing in  the  valves  becoming  incompetent  to  close  the  orifices,  and  this 
latter  efifect  is  added  to  by  the  removal  of  the  basis  of  the  papillary 
muscles  a  greater  distance  from  the  orifice,  in  consequence  of  the 
extension  of  the  wall. 

When  the  auricles  dilate,  the  large  venous  trunks  opening  into  them 
unprotected  by  valves  commonly  participate  in  the  dilatation,  and 
may  become  greatly  enlarged. 

The  passive  congestion  of  the  organs  that  follows  the  feeble  circu- 
lation produces  changes  in  their  structure. 

Symptoms.  Those  associated  with  enfeebled  circulation — to  wit : 
Feeble  pulse,  veins  distended,  arteries  emptied  ;  headache,  aggravated 
by  the  upright  position  ;  attacks  oi syncope,  cough,  with  any  of  the  fol- 
lowing phenomena  of  venous  congestion;  of  the  lungs,  dyspnoea; 
Wvtr,  Jaundice ;  stomach,  dyspepsia;  intestines,  constipation;  kid- 
neys, scanty,  often  albuminous,  urine ;  brain,  dullness  of  the  mind 


DISEASES   OF  THE   CIRCULATORY   SYSTEM.  381 

and  vertigo,  often  relieved  by  a  copious  epistaxis  ;  and,  finally,  dropsy, 
beginning  in  the  lowerextremities,  the  patient  dying  from  exhaustion. 

Great  relief  often  temporarily  follows  any  of  the  above  symptoms 
under  treatment ;  sooner  or  later,  however,  the  venous  stasis  produces 
the  final  symptoms  noted. 

Inspection.  Veins  of  the  surface  distended  and  enlarged ;  in- 
distinct cardiac  impulse,  often  diffused  and  wavy  ;  if  associated  with 
tricuspid  insufficiency,  there  is  pulsation  of  the  jugular. 

Palpation.     Feeble  and  irregular  fluttering,  but  heaving  impulse. 

Percussion.  Cardiac  dullness  extended  transversely,  and  espe- 
cially increased  on  the  right  side. 

Auscultation.  If  no  valvular  lesion  accompany  the  dilatation, 
the  cardiac  sounds  are  weaker  than  normal,  the  first  sounds  having  a 
sharper  quality  than  normal ;  if  accompanied  by  valvular  lesions, 
cardiac  murmurs  are  present. 

Diagnosis.  Hypertrophy  of  the  heart  shows  increased  cardiac 
dullness,  and  is  a  disease  of  powerful  cardiac  action,  while  dilatation 
is  an  affection  of  feeble  action  associated  with  dropsy. 

Pericardial  effusion  has  many  points  of  resemblance  to  cardiac 
dilatation,  but  it  begins  suddenly,  associated  with  some  acute  malady, 
and  while  the  heart  sounds  are  indistinct  or  feeble  at  the  apex,  they 
both  have  their  normal  qualities  at  the  cardiac  base,  while  dilatation 
of  the  heart  has  a  chronic  history,  results  in  general  venous  stasis,  the 
cardiac  sounds  being  of  the  same  intensity  over  the  entire  prsecordium. 

Prognosis.  Unfavorable,  death  resulting  from  gradual  exhaus- 
tion, or  suddenly  by  cardiac  paralysis  if  there  be  some  undue  excite- 
ment.    With  careful  living  life  may  be  prolonged  for  years. 

Treatment.  Dilatation  of  the  heart  is  incurable.  In  all  cases 
there  are  two  important  indications  :  The  first  to  maintain  the  general 
nutrition  of  the  patient,  and  the  second  to  control  or  prevent  all 
irregular  or  violent  cardiac  action.  The  first  is  accomplished  by  a 
generous  diet,  moderate  exercise,  with  bitters  to  increase  the  appetite 
QXiA.  ferrtim  to  improve  the  blood,  and,  in  a  majority  of  cases,  the 
more  or  less  free  use  of  a  good  red  wine. 

The  second  indication  is  met  by  the  observance  of  strict  rules  in 
regard  to  exercise  and  such  heart  tonics  as  digitalis  in  powder,  tinc- 
ture, or  infusion,  or  a  combination  like  the  following  : 

R.     Tincturce  nucis  vomicae,    .    .    .    .  f^ss  15.  Cc. 

Tincture  digitalis, f^ss  15.  Cc.  M. 

SiG. — Fifteen  to  twenty  drops  after  meals,  in  water. 


3!S2  PRACTICE    OF    MEDICINE. 

Drs.  Hare  and  Coplin  have  demonstrated  by  careful  research  that 
the  prolonged  use  of  digitalis  actually  increased  the  development  of 
the  normal  heart  muscle. 

StrychnincE  sulphas,  gr.  ^^  (0.0025  Gm.),  three  times  daily,  is  a 
valuable  cardiac  tonic  ;  the  same  may  be  said  of  caffeina:  citrala,  gr. 
j-iij  (0.06-0.2  Gm.),  three  or  four  times  daily.  Sparteina  sulpJuis  is  a 
powerful  cardiac  tonic,  particularly  of  service  in  the  dilating  heart  of 
Bright's  disease.  The  tinctura  strophanthus,  alone  or  in  combina- 
tion with  digitalis,  is  valuable.  Extractum  convallaiiae  fluidum  is 
not  always  reliable.  Morphince  sulphas  in  small  doses,  particularly 
when  compensation  is  failing  and  the  dropsy  becomes  great  and 
is  associated  with  marked  cyanosis,  hypodermically,  as  suggested  by 
Prof.  Bartholow,  "  often  acts  like  magic  in  restoring  the  circulation." 

The  following  pill  is  often  of  great  advantage  : 

BL.     Ferri  reduct. , gr.  j-ij  .065-.  i3Gm. 

Quininas  suljih., g""- j~'j  .065-.13  Gm. 

I'ulv.  digitalis, gr.  j  .065  Gm. 

Moqihinae  sulph. , g*"-  2*1  0025        Gm.  M. 

SiG. — Three  times  a  day. 

An  excellent  combination  is  the  following: 

R.     Tinct.  digitalis, f  z  iss  6.  Cc. 

Tinct.  cacti  grandiflor f^j  30.  Cc. 

Caffeine  citrata X)  4.  C>m. 

Tinct.  card.  comp. ad  f  _^  iv        ad         120.  Cc.  M. 

SiG. — Teaspoonful,  diluted,  three  or  four  times  daily. 

The  bowels,  skin,  and  kidneys  should  be  kept  in  action,  using,  if 
needed,  purgatives,  diaphoretics,  and  diuretics.  The  following  combi- 
nation, suggested  by  Dr.  J.  M.  Anders,  is  satisfactory  in  many  in- 
stances : 

B .     Caffeinae  citrata, 3  j  4.         Gm. 

Strychnine  sulph., g""-  K  .022  Gm. 

Sparteinru  .sulph., gr- ij  •'^1    Gm.         M. 

Ft.  capsula;  No.  xij. 

SiG. — One  every  three  or  four  hours. 

Or  the  following  excellent  diuretic  pill: 

R.     Pulv.  scilla: gr.  xxx  2.  Gm. 

Pulv.  digitalis, gr.  xxx  2.  Gm. 

Cafl'eina-  citrata, gr.  xxx  2.  Gm. 

Hydrarg.  chlor.  mitis, gr.  v  .3  Gm.  M. 

Ft.  piiuU«  No.  xxx. 

SiG. — One  three  or  four  times  daily. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM.  383 

If  pulmonary  congestion  develop,  dry  cups,  digitalis,  caffeiyui,  atro- 
pina,  and  stimulants. 

For  cardiac  asthma,  dry  cups,  morpMncz  sulphas,  hypodermically, 
or  spiritus  cetheris  compositus  (Hoffman's  Anodyne). 

For  hepatic  congestion,  blue  mass  or  podophyllin. 

For  dropsy,  dry  cups  over  the  kidney,  digitalis  with  potassii  acetas, 
with  scoparius  diXid  juniperus ,  2indi pulv.jalapce  comp.,  3j-ij  (4-8  Gm.), 
in  water,  before  breakfast. 

If  the  dropsy  is  uninfluenced  by  the  above  means,  success  will 
follow  the  use  of  hydrargyri  chloridi  mitis,  gr.  iij  (0.2  Gm.),  guarded 
with  pulves  opii,  gr.  ^^^  (0.005  Gm.),  three  or  four  times  a  day. 

The  treatment  of  cardiac  dilatation  and  cardiac  failure  by  baths 
and  systematic  exercise  has  excited  much  interest  and  discussion  re- 
cently, with  the  result  of  its  indorsement  in  proper  cases.  Exercise  is 
employed  in  one  of  three  plans  or,  rarely,  a  combination  of  these 
plans  :  (i)  passive  exercise  and  massage  (Swedish  or  Ling  plan)  ;  (2) 
movements  with  limited  resistance  (Schott  plan,  but  really  a  modifi- 
cation of  the  Swedish);  (3)  method  of  climbing  (Oertel).  The  baths 
to  be  those  of  the  Nauheim  (saline)  natural  waters.  A  number  of 
American  and  English  clinicians  report  good  results  with  artificial 
Nauheim  baths.  This  system  of  cardiac  treatment  is  associated  with 
regulated  diet  and  the  use  of  some  cardiac  tonics,  and  business  rest. 


ACUTE  MYOCARDITIS. 

Synonyms.     Carditis  ;  abscess  of  the  heart. 

Definition.  An  inflammation  of  the  muscular  tissue  of  the  heart, 
by  extension  from  an  inflamed  pericardium  or  endocardium,  or  sec- 
ondary to  pyaemia ;  characterized  by  pain,  feeble  circulation,  symp- 
toms of  blood-poisoning  and  collapse. 

Causes.  The  result  of  endocarditis  or  pericarditis  ;  pyaemia ; 
typhoid  fever;  emboli  of  the  coronary  arteries. 

Pathological  Anatomy.  Discoloration  and  softening  of  the 
cardiac  substance  and  the  infiltration  of  a  sero-sanguineous  fluid, 
fibrinous  exudation  and  pus,  leading  to  the  formation  of  abscesses  in 
the  muscular  structure  of  the  heart. 

The  disease  leads  to  the  formation  of  either  a  cardiac  aneurism  or 


384  PRACTICE    OF    MEDICINE. 

to  rupture  of  the  walls  of  the  heart.  If  recovery  occur,  cicatrices  or 
depressed  scars  may  mark  the  site  of  a  former  abscess. 

Symptoms.  The  clinical  evidences  of  inflammation  of  the  car- 
diac muscles  are  very  obscure.  If,  during  the  course  of  one  of  the 
maladies  mentioned,  there  are  developed  pracordial  pain,  irregular 
and  feeble  cardiac  acfion,  cardiac  dyspna'a,  pyrexia  of  a  low  type, 
with  symptoms  of  blood-poisoning  and  a  tendency  to  collapse,  or  the 
symptoms  of  the  so-called  typhoid  state,  myocarditis  may  be  suspected. 

Diagnosis.  The  existence  of  myocarditis  can  scarcely  ever  be 
anything  but  a  presumption,  the  signs  being  all  negative  rather  than 
positive.  If  during  the  course  of  rheumatism,  pyaemia,  puerperal 
fever,  typhoid  fever,  pericarditis,  or  endocarditis,  symptoms  of  cardiac 
failure  appear  suddenly,  associated  with  signs  of  blood-poisoning  and 
collapse,  inflammation  of  the  cardiac  muscle  may  be  suspected. 

Prognosis.  The  course  of  acute  myocarditis  is  very  rapid,  death 
being  the  usual  termination  in  from  three  to  five  days.  Chronic 
myocarditis  pursues  a  very  latent  course. 

Treatment.  Largely  symptomatic.  Perfect  rest  of  mind,  gen- 
erous diet,  free  stimulation,  and  the  administration  of  quinina  sul- 
phas, ferrum,  and  spiritus  cetheris  nitrosi — a  nitrite. 


CHRONIC  MYOCARDITIS. 

Synonyms.  Fibroid  heart;  chronic  interstitial  myocarditis; 
fibrous  myocarditis  ;  chronic  carditis  ;  cardio-sclerosis. 

Definition.  A  slowly  developing  hyperplasia  of  the  interstitial 
connective  tissue  of  the  heart,  leading  to  induration  of  its  substance; 
characterized  by  shortness  of  breath  on  slight  exertion,  attacks  of 
tachycardia,  prsecordial  pain,  disordered  circulation,  and  vertigo. 
It  is  proper  to  state  that  many  cases  present  no  symptoms  whatever. 

Causes.  The  most  frequent  cause  is  sclerosis  of  the  coronary 
arteries,  leading  to  imperfect  blood  supply  to  the  cardiac  muscles. 
Among  other  frequent  causes  are  diseases  of  the  kidneys,  alcohol- 
ism, excessive  use  of  tobacco,  syphilis,  secondary  to  pericarditis,  en- 
docarditis, and  acute  myocarditis. 

There  is,  undoubtedly,  often  an  inherited  predisposition  to  fibroid 
changes  in  the  vessels,  in  which  cases  the  causes  named  would  act 
as  exciting  causes. 


DISEASES   OF  THE  CIRCULATORY  SYSTEM.  385 

It  is  a  disease  of  the  aged,  save  in  those  instances  resulting  from 
hereditary  predisposition  or  from  excesses.  The  old  saying,  "  A  man 
is  as  old  as  his  arteries,"  is  applicable  to  this  disease. 

Pathological  Anatomy.  The  heart  is  enlarged  and  dilated. 
The  morbid  changes  may  be  diffused,  or  limited  to  the  walls  of  the 
left  ventricle,  the  papillary  muscles,  and  the  septum.  There  is  always 
more  or  less  atheromatous  deposit  or  changes  in  the  aorta.  All  cases 
show  atheroma  in  one,  more,  or  all  of  the  coronary  arteries.  Com- 
plete closure  of  one  coronary  artery,  if  produced  suddenly,  is  usually 
fatal. 

On  section,  the  cardiac  wall  cuts  with  a  distinct  resistance.  The 
changes  in  the  heart  wall  are  an  "  overgrowth  of  the  interfibrillar  con- 
nective tissue,  with  development  of  fibrous  tissue.  These  changes 
may  be  uniformly  distributed  through  the  substance  of  the  heart  when 
some  intoxication,  as  by  alcohol,  or  some  general  disturbance  of  the 
cardiac  nutrition,  has  led  to  the  myocardial  disease  ;  or  they  may  be 
seen  in  circumscribed  areas  when  embolic  or  thrombotic  occlusion  of 
branches  of  the  coronary  arteries  has  occasioned  anaemic  infarction 
and  subsequent  sclerosis.  In  either  case  the  microscope  reveals 
masses  of  wavy  fibrous  tissue  between  the  muscular  bundles,  and 
often  slow  degeneration  or  atrophy  of  the  fibres  themselves  "  (Pepper). 

The  terminal  branches  of  the  coronary  arteries  are  narrowed  and 
sclerotic  to  the  point  of  obliteration,  particularly  in  cases  resulting 
from  syphilis. 

"Aneurism  of  the  heart  is  commonly  due  to  localized  cardio- 
sclerosis. The  inelastic  fibrous  tissue  gradually  gives  way  before  the 
intracardial  pressure,  and  saccular  dilatation  results  "  (Pepper). 

Atheromatous  changes  are  often  found  in  other  than  the  coronary 
vessels,  particularly  the  aorta. 

Various  degenerative  changes  occur  in  other  organs,  the  result  of 
disturbed  circulatory  action. 

Symptoms.  The  great  majority  of  patients  having  chronic  myo- 
carditis present  no  symptoms  until  an  extra  cardiac  effort  is  called 
for. 

An  early  symptom  is  breathlessness  on  slight  exertion,  with  either 
cardiac  palpitation  or  2l  feeble,  irregular  pulse.  Vertigo  is  frequent 
and  distressing,  increased  by  indigestion  and  costive  bowels.  An- 
ginal attacks  (cardiac  pain)  or  a  sensation  of  constriction  or  pressure 
over  the  prascordium  are  frequent,  often  following  some  exertion  or  an 
35 


386  PRACTICE    OF    MEDICINE. 

attack  of  indigestion.  The  pulse-rate  is  often  decreased  in  frequency 
in  cases  which  present  no  other  symptom. 

A  frequent  symptom  is  syncope,  coming  without  warning  or  after 
sudden  exertion,  the  result  of  sudden  failure  of  thecerebral  circulation. 

Among  other  periodical  symptoms  are  cardiac  asthma,  pseudo- 
apoplectic  attacks,  and  hepatic,  gastric  and  nephritic  disorders. 

As  the  fibroid  changes  progress,  there  develop  progressive  weak- 
ness, dyspnoea,  insomnia,  disordered  digestion,  and  cerebral  weak- 
ness, often  showing  itself  as  mania,  delusional  attacks,  or  dementia. 

Percussion.  Increased  praecordial  dullness  is  usually  present, 
due  to  the  dilated  hypertrophy. 

Auscultation.  The  first  sound  of  the  heart  is  valvular  in  char- 
acter, the  booming  or  muscular  quality  having  disappeared.  Mur- 
murs are  very  frequent,  the  result  of  valvular  disease.  A  very 
characteristic  condition  is  the  irregularity  in  rhythm  and  in  force,  one 
contraction  being  fairly  forcible,  another  weak  or  feeble,  and  so  on. 

Diagnosis.  A  proper  appreciation  of  chronic  myocarditis  is  one 
of  the  most  important  questions  in  clinical  medicine.  The  term 
''  Heart  Failure''  is  the  opprobrium  of  the  profession,  and  yet  chronic 
myocarditis  is  one  of  the  great  causes  of  cardiac  failure  during  the 
prevalence  of  some  over-exertion  or  in  acute  pneumonia,  typhoid 
fever,  and  other  like  diseases. 

The  points  of  value  in  arriving  at  a  diagnosis  are  :  a  careful  study 
of  the  first  sound  of  the  heart  at  the  apex  ;  the  character  of  murmurs 
if  present,  the  condition  of  the  arteries,  the  dyspnoea,  the  feeble, 
irregular  pulse  in  patients  past  fifty  years,  and  the  occurrence  of 
anginal  attacks  after  exertion  or  mental  worry. 

Prognosis.  This  is  controlled  by  the  habits  of  the  patient.  The 
disease  is  incurable,  but  life  may  be  fairly  comfortable  for  many  years 
if  care  be  exercised. 

Treatment.  No  remedy  can  remove  the  fibroid  change.  The 
indications  are  to  promote  the  patient's  nutrition,  hold  in  check  the 
progress  of  the  fibrosis,  and  meet  or  prevent  the  symptoms  as  they 
arise.  Constipation  is  often  a  troublesome  symptom,  and  calls  for 
such  drugs  as  aloes  or  cascarcs  sagrada. 

For  the  general  zond\\\on,  fcrriim ,  arsettiaim,  and  the  hypophos- 
phiies. 

For  the  breathlessness,  spiritus  glonoini  (nitroglycerin,  one  per 
cent.),  or  spiritus  cetheris  nitrosi,  or  spiritus  ammonics  aromaticus. 


DISEASES   OF  THE  CIRCULATORY  SYSTEM.  387 

For  cardiac  palpitation,  potassii  bromidum,  lithii  broniidtmt,  or 
spiritus  ammonicB  aromatictis. 

For  cardiac  weahtess,  strychnince  sulphas,  gr.  -^-^  (0.0025  Gm.),  three 
or  four  times  a  day,  and  if  the  pulse  is  frequent,  tinctura  digitalis, 
Tt\,x-xx  (0.6-1.2  Cc),  three  times  daily,  or  caffeines  citrata,  gr.  iij 
(0.2  Gm.),  after  meals  ;  maintaining  the  recumbent  position  and  re- 
moving all  unfavorable  associate  symptoms,  as  constipation,  scanty 
urine,  and  dyspepsia  with  flatulence. 

For  the  angijtal  attacks,  hypodermic  injections  of  niorphince  sul- 
phas, gr.  yk-)i  (0.008-0.016  Gm.),  or  chlorodyne,  ttlx-xx  (0.6-1.2  Cc), 
repeated  as  needed. 

Yorihe  syncopal  attacks,  ihQ'pz.tXenX.  should,  be  placed  in  bed  and 
stimulants  administered,  often  used  by  the  hypodermic  method,  with 
mustard  over  the  praecordium,  and  Ti^j-ij  (0.06-0.12  Cc.)  spiritus 
glo7toini  every  couple  of  hours. 

An  excellent  combination  for  breathlessness,  vertigo,  and  chest 
pains  is  : 

R.     Lithii  bromidi, ^vss  22.  Gm. 

Spirit!  glonoini, fl^xv]  I.  Cc. 

Liq.  potassii  citratis,  .    .  q.  s.  ad    f§viij  ad     240.  Cc.  M. 

SiG. — Tablespoonful  four  times  daily,  diluted. 

The  patient  must  lead  a  quiet  life,  refrain  from  mental  worry,  phy- 
sical over-exertion,  and  eschew  tobacco  and  malt  liquors.  The  diet 
must  be  plain  and  simple,  with  but  little  tea  or  coffee.  In  the  elderly, 
a  small  amount  of  good  whisky  once  or  twice  a  day  is  valuable. 


FATTY  HEART. 

Synonyms.  Fatty  degeneration  of  the  heart ;  chronic  myo- 
carditis. 

Definition.  A  change  in  the  muscular  fibres  of  the  heart,  in 
which  the  transverse  strise  are  replaced  by  granules  and  globules 
of  fat;  characterized  by  feeble  cardiac  action,  venous  stasis,  and 
dyspnoea. 

Causes.  Impaired  nutrition  in  the  elderly  ;  prolonged  anaemia  ; 
chronic  gout ;  alcoholism  ;  phosphorus  poisoning  ;  cancer  ;  tubercu- 
losis and  scrofula;  diseases  of  the  coronary  arteries. 

Pathological  Anatomy.     The  distinction  must  be  made  be- 


388  PRACTICE    OF    MEniClNE. 

tween  a  deposit  of  fatly  tissue  upon  or  around  the  heart,  and  the 
degeneration  of  its  muscular  tissue. 

The  fatty  metamorphosis  may  affect  the  whole  organ,  or  the  entire 
ventricular  walls,  or  be  limited  to  portions  of  them.  If  the  degenera- 
tion be  marked,  the  color  is  yellowish,  the  tissues  soft  and  easily  torn, 
and  to  the  touch  have  a  greasy  feeling,  oil  being  yielded  on  pressure. 

The  microscopic  changes  are  characteristic.  The  striae  of  the 
muscle  are  easily  rendered  indistinct  by  fat  and  oil  globules,  grad- 
ually becoming  more  and  more  obscured,  and  finally  disappearing 
altogether,  the  fibres  being  replaced  by  fat  granules. 

Symptoms.  Those  of  weak  heart,  anaemia  of  organs,  and 
venous  stasis — to  wit :  feeble,  irregular,  but  slow  cardiac  action  ;  com- 
pressible pulse,  prcEcordial  distress,  often  aggravated  by  attacks  of 
angina  pectoris  ;  dyspnoea,  aggravated  on  exertion,  with  anaemia  of 
the  various  organs  from  the  feeble  propulsive  power;  if  of  brain, 
vertigo,  swooning,  or  pseudo-epileptic  attacks,  especially  marked  on 
suddenly  rising  from  a  recumbent  position  ;  if  of  lungs,  dry,  hacking 
cough  ;  if  of  gastro-intestinal  tract,  dyspepsia  and  constipation  ;  if  of 
kidneys,  scanty  urine,  at  times  albuminous,  and  finally  dropsy,  begin- 
ning in  the  lower  extremities. 

A  formidable  symptom,  causing  much  inconvenience  as  well  as 
alarm  to  the  patient,  is  what  he  will  term  his  constant  "  sighing,"  the 
Cheyne-Stokes  breathing — "A  pause  in  the  breathing,  a  complete 
suspension  of  the  respiratory  acts  for  a  period  of  time  (during  which 
breathing  might  occur  several  times  in  the  normal  manner),  then  the 
resumption  of  respiration  very  feebly  and  slowly,  and  a  gradual  and 
progressive  increase  in  the  number  and  depth  of  respirations  until 
the  maximum  is  reached,  and  then  again  a  gradual  and  progressive 
diminution  in  the  same  order,  in  the  number  and  depth  of  the  res- 
pirations, until  another  pause  occurs  " — the  "  oscillating  respiration." 

Concomitant  symptoms  are  atheromatous  changes  in  the  vessels, 
and  the  arcus  senilis. 

Palpation.     Weak  cardiac  impulse. 

Percussion.  Not  markedly  changed  unless  preceded  by  enlarge- 
ment of  the  heart. 

Auscultation.  First  sound  feeble,  toneless,  almost  inaudible, 
the  second  sound  being  normal,  unless  changes  in  the  valves  are 
present. 

Diagnosis.     Feeble  cardiac  sounds,  with  slow  pulse,  attacks  of 


DISEASES   OF  THE   CIRCULATORY  SYSTEM.  389 

cardiac  asthma  or  Cheyne-Stokes  breathing,  with  evidences  of  arcus 
senilis,  make  the  diagnosis  very  certain.  The  question  of  fibroid 
heart  must  always  be  considered. 

Prognosis.  Incurable,  the  affections  pursuing  a  more  or  less 
chronic  course.  Life  may  be  prolonged  at  times  by  treatment,  but 
death  finally  results  from  exhaustion,  or  suddenly  from  cardiac 
paralysis  or  rupture  of  the  heart. 

Treatment.  Incurable,  there  being  no  plan  of  treatment  that 
can  restore  the  degenerated  muscular  fibre.  Generous  diet,  very 
moderate  exercise,  stimulants,  oleum  titorrhucE,  and  the  "  triple 
elixir  " — elixir ferri,  quinines,  et  strychjiince,  or  the  hypophosphites. 

All  the  excreting  organs  must  be  kept  active,  so  as  to  relieve  the 
crippled  heart  as  much  as  possible. 

To  sustain  the  cardiac  action,  strychnince  sulphas,  gr.  -j^-^  (0.002- 
0.0015  Gm.),  three  or  four  times  daily,  is  most  valuable.  Other  drugs 
are  caffeince  citrata,  spartei?tcB  sulphas,  or  tinctura  nucis  vomiccB. 
Digitalis  is  contra-indicated  in  advanced  cases. 

For  syncopal  attacks,  nitro-glycerimim  {spiritus  glonoini),  spiritus 
(Etheris  nitrosi,  spiritus  amtnonicB  aromaticus,  or  hypodermic  injec- 
tions of  CEtheris,  camphora,  or  spiritus  frumetiti. 

The  recumbent  position  for  hours  each  day  is  a  valuable  means 
of  resting  a  crippled  heart. 


PALPITATION  OF  THE  HEART. 

Synonym.     Irritable  heart. 

Definition.  A  functional  disturbance  of  the  heart;  characterized 
by  increasing  frequency  of  its  movements  and  more  or  less  irregu- 
larity of  the  rhythm,  with  a  strong  tendency  toward  hypertrophy. 

Causes.  Over-exertion,  "  the  heart-strain  "  of  Da  Costa  ;  dyspep- 
sia ;  uterine  diseases ;  excesses  in  tea,  coffee,  tobacco,  alcohol,  or 
venery  ;  moral  and  emotional  causes,  grief,  anxiety,  and  fear. 

Symptoms.  Usually  palpitation  of  the  heart  has  a  sudden  onset 
after  some  one  of  the  causes  mentioned,  with  prcecordial  oppression 
or  pain  ;  rapid,  tumultuous  beating,  the  impulse  being  visible  through 
the  patient's  clothing  ;  dyspitcea,  atixiety,  and  a  sense  of  choking  or 
fullness  in  the  throat,  the  recumbent  position  being  impossible;  vertigo, 
faintness,  flashes  of  light,  the  pulse  full  and  strong  or  feeble,  the  face 


390  PRACTICE    OF    MEDICINE. 

flushi-d  or  pale,  the  patient  having  a  feeling  of  anxiety  with  a  sense 
oi  impending  danger  and  a  fear  of  sudden  death.  These  attacks  are 
paroxysmal,  lasting  from  a  few  moments  to  several  hours,  or  a  day, 
the  patient  often  voiding  a  large  quantity  of  limpid  urine  after  the 
paroxysm  has  subsided,  when  there  is  a  strong  tendency  to  sleep. 

Diagnosis.  Irritability  of  the  heart  is  differentiated  from  the 
various  forms  of  cardiac  disease  by  the  absence  of  all  the  physical 
signs  mentioned  as  occurring  in  those  conditions. 

Prognosis.     If  early  and  properly  treated,  favorable. 

Treatment.  The  first  point  in  the  treatment  of  irritability  of  the 
heart  is  to  remove  the  cause  ;  the  next,  to  prevent  the  recurrence  of 
the  attacks  of  palpitation. 

The  majority  of  cases  do  well  after  a  few  doses  of  either  spiritus 
atheris  r<7;«/<?j/7«i  (Hoffman's  anodyne)  or  spirilus  amvionii  aromati- 
cus,  or  a  combination  of  digitalis  and  belladonna.  Permanent  relief  is 
often  afforded  by  a  combination  oi  poiassii  bromidiim  and  verairwn 
viride.  Trional,  gr.  x-xv  (0.6-1  Gm),  three  times  daily,  is  often  use- 
ful. If  the  patient  be  aniemic,  excellent  results  follow  the  prolonged 
use  of  the  elixir  feni,  quinines,  et  sirychnincp.  Locally,  emplastritm 
belladomicE  to  the  praecordium  affords  relief.  The  acute  attack  is 
often  wonderfully  benefited  by  ice  over  the  praecordium. 


TACHYCARDIA. 

Synonyms.     Rapid  heart ;  quick  heart ;  paroxysmal  rapid  heart. 

Definition.  Paroxysmal  rapid  cardiac  action,  minus  or  with  sub- 
jective symptoms,  the  result  of  excessive  cardiac  rapidity. 

Causes.  Tachycardia  is  one  of  the  "  crises"  of  cerebral  or  spinal 
diseases.  Menopause.  Neuritis  of  the  pneumogastric  nerve;  chronic 
myocarditis  ;  neurasthenia ;  chronic  gastritis ;  excessive  use  of  to- 
bacco (?) ;  a  variety  of  petit  mal  (?). 

Pathological  Anatomy.  No  characteristic  lesions.  There 
may  be  paralysis  of  the  inhibitory  fibers  of  the  vagus,  an  irritation  of 
the  accelerators  of  the  sympathetic,  or  reflex  action  from  some  lesion 
in  the  cardiac  wall  or  elsewhere. 

Symptoms.  The  paroxysm  is  sudden  in  its  onset,  with  or 
without  "  warnings  " — if  these  latter,  they  are  in  the  shape  of  vertigo, 
ringing  in  the  ears,  and  a  sense  of  impending  danger.     The  cardiac 


DISEASES   OF  THE  CIRCULATORY  SYSTEM.  391 

action  is  increased  to  150,  175,  200,  rarely  250  beats  per  minute.  The 
pulse  is  small,  weak,  easily  compressible,  and  often  irregular,  with 
carotid  pulsation  (which  indicates  the  emptiness  and  low  tension  of 
the  artery,  as  in  aortic  regurgitation).  The  respiration  is  slightly 
increased ;  rarely  there  is  dyspnoea.  The  surface  is  at  first  pale,  but 
soon  becomes  flushed.  The  expression  is  anxious  and  denotes  suffer- 
ing. There  is  a  feeling  of  preecordial  constriction,  with  more  or  less 
smothering.     Rarely,  there  are  no  subjective  symptoms. 

The  duration  is  from  a  few  minutes  to  hours,  or  days.  The  attack 
usually  ceases  during  sleep,  but  if  it  does  not,  the  rapidity  of  the  pulse 
continues  during  the  disturbed  sleep. 

Auscultation.  The  first  sound  is  clear  and  ringing,  but  not 
strong  and  booming.  The  second  sound  is  weak  and  lacks  the  val- 
vular quality  of  the  normal.     A  murmur  is  often  heard  at  the  apex. 

Diag"nosis.  The  differentiation  between  tachycardia  and  palpi- 
tation is  to  be  made,  as  also  the  rapid  heart  of  valvular  disease  and 
of  irritable  heart.  The  chief  point  is  that  in  tachycardia  the  attack 
is  paroxysmal,  and  the  number  of  pulsations  exceeds  the  rapid  heart 
of  other  conditions. 

Prognosis.  It  is  often  an  unfavorable  symptom  of  some  central 
lesion.  If  it  develop  in  patients  suffering  from  chronic  myocarditis 
or  atheroma  of  vessels,  the  fatal  result  may  be. sudden. 

Treatment.  For  Xheparoxystn,  the  application  of  ice  to  the  prae- 
cordium,  conjoined  with  a  hypodermic  injection  o{  morphince  sulphas, 
gr.  Yd  (o.oii  Gm.),  and  atropines  sulphas,  gr.  ^^  (0.00065  Gm.),  and 
rest  in  bed.  A  few  large  doses  of  digitalis  should  always  be  tried. 
Tinctura  belladonncE,  potassii  bromidum,  lithii  broviidian,  stroniii 
bromidum,  or  camphorcE  monobroinas  are  often  valuable  ;  remember- 
ing that  which  answers  in  one  case  or  attack  may  be  useless  in 
another.  Trional,  gr.  xxx  (2  Gm.),  seems  to  rapidly  control  a 
paroxysm.     An  ice  bag  over  the  prascordium  has  cut  short  an  attack. 

The  arrest  of  attacks  of  tachycardia  is  reported  from  compression 
of  the  vagus  in  the  neck.  Nothnagel  reports  the  case  of  a  patient 
who  could  cut  short  an  attack  by  a  full  and  deep  inspiration. 

Rosenfeld  succeeded  in  cutting  short  an  attack  in  four  cases  by 
having  "  the  patient  squeeze  his  own  arms  and  elbows  into  his  sides, 
and  at  the  same  time  forcibly  compress  his  abdomen." 

After  the  paroxysm,  nutritious  diet,  avoidance  of  alcohol,  tobacco,  tea, 
and  coffee,  and  a  course  of  arsenicum,  strychnina,  or  potassii  iodidum. 


392  PRACTICE    OF    MEDICINE. 


BRADYCARDIA. 


Synonjnn.     Brachycardia. 

Definition.  A  paroxysmal  or  permanent  slowness  in  the  cardiac 
action.  It  is  agreed  that  bradycardia  begins  with  a  pulse  reduced  to 
at  least  forty  beats  per  minute. 

Causes.  Often  associated  with  organic  nervous  diseases.  It  is  a 
symptom  of  such  cardiac  diseases  as  fibroid  and  fatty  heart  and 
atheroma  of  the  coronary  arteries. 

It  frequently  occurs  during  convalescence  from  infectious  diseases, 
such  as  diphtheria,  pneumonia,  typhoid  fever,  erysii)elas,  and  rheu- 
matism ;  ur;cmia,  lead-poisoning,  ana-mia,  and  chronic  alcoholism 
are  often  causes.  Balfour  says  :  "  Many,  if  not  most,  of  the  sufferers 
from  bradycardia  are  epileptics." 

Symptoms.  Slow  action  of  the  heart  is  the  chief  symptom, 
varying  from  40,  30,  20,  to  10  or  8  beats  per  minute.  The  pulse  is 
weak,  small,  and  slow.  As  results  of  the  slow  cardiac  action  are 
vertigo,  noises  in  the  ears,  syncopal  attacks,  and  rarely  convulsions. 
The  onset  may  be  either  sudden  or  follow  "  warnings." 

Auscultation.  The  first  sound  is  soft  and  feeble,  and  often  the 
second  sound  is  not  heard. 

As  a  rule,  with  reduction  in  the  number  of  contractions  is  an  in- 
crease in  their  force,  and  this  not  obtaining  in  bradycardia  determines 
its  central  origin. 

Diagnosis.  A  feeble  cardiac  contraction,  with  less  than  forty 
beats  per  minute,  determines  the  diagnosis. 

Prog"nosis.  Sudden  death  a  very  frequent  termination.  The 
cause  controls  the  prognosis. 

Treatment.  So  long  as  the  slow  cardiac  pulsations  are  sufficient 
to  supply  the  requirements  of  the  economy,  medication  is  not 
needed;  when,  however,  the  reverse  obtains,  resort  to  rest  in  the  re- 
cumbent position,  heat  to  the  pra^cordium,  and  the  use  of  such  reme- 
dies as  atropincB  sulphas,  caffeitiCB  citrata,  strychtiince  sulphas,  spiritus 
glonoini,  or  spiritus  ammonice  aromaticus.  Often  the  emergency  is 
so  great  as  to  call  for  the  hypodermic  use  of  the  selected  drug. 

Digitalis  is  contra-indicated.  Between  the  paroxysms,  such  reme- 
dies as  improve  the  general  health  and  prevent  the  progress  of  the 
central  or  exciting  cause. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM.  393 


ARRHYTHMIA. 

Synonyms.     Arrhythmia  cordis ;  irregularity  of  the  pulse. 

Definition.  A  lack  of  cardiac  rhythm,  or  irregularity  in  the  car- 
diac pulsations.     It  is  a  symptom  rather  than  a  disease. 

Causes.  Valvular  diseases  ;  myocardial  diseases  ;  cardiac  dilated 
hypertrophy  ;  atheroma  of  coronary  arteries  and  aorta  ;  excessive  use 
of  tobacco,  tea,  or  coffee  ;  flatulent  dyspepsia.  Neurasthenia,  hysteria, 
and  melancholia. 

Symptoms.  An  irregularity  in  cardiac  action,  either  in  the 
rhythm  or  the  regularity  of  \}s\&  force  of  the  beats,  or  an  intermission 
in  the  cardiac  contractions. 

The  sphygmograph  gives  the  exact  condition  of  the  cardiac  pulsa- 
tions and  should  always  be  used  in  cardiac  diseases. 

Other  symptoms  that  may  be  present  are  due  to  the  condition  pro- 
ducing the  arrhythmia. 

Diagnosis.  An  examination  of  the  pulse,  auscultation  of  the 
heart,  and  the  use  of  the  sphygmograph  determine  the  arrhythmia. 

Prognosis.  Depends  upon  the  cause.  In  functional  cases  favor- 
able, in  organic  cases  unfavorable. 

Treatment.  Rest  of  mind  and  body,  regulated  diet,  and  atten- 
tion to  the  secretions. 

Tinctura  micis  vomicce,  strychnince  sulphas,  and  digitalis  are  each 
useful.     In  functional  cases  the  bromides  are  valuable. 


ANGINA  PECTORIS. 

Synonyms.     Neuralgia  of  the  heart ;  breast-pang. 

Definition.  Paroxysms  in  which  there  occur  sharp  cardiac  pains, 
extending  usually  into  the  left  shoulder  and  down  the  left  arm,  ac- 
companied by  a  feeling  of  constriction  of  the  thorax  and  a  strong 
fear  of  impending  death. 

Causes.  Often  hereditary  ;  associated  with  chronic  cardiac 
changes,  disease  of  the  coronary  arteries  or  calcification  of  the 
valves ;  the  excessive  use  of  tobacco  (?) ;  syphilis  ;  according  to  Trous- 
seau, it  is  a  form  of  masked  epilepsy,  and  may  alternate  with  true 
epileptic  attacks.     Often  associated  with  hysteria  (?). 


394  PRACTICE   OF    MEDICINE. 

Patholo^cal  Anatomy.  A  disease  of  the  arteries,  ossification 
and  occasionally  obliteration  of  the  cardiac  arteries,  producing  car- 
diac ischaimia. 

"The  pathological  changes  which  stand  in  a  causative  relation  to 
the  attacks  are  those  of  the  cardiac  plexus  of  the  phrenic  and  of  the 
pneumogastric  nerves.  Pressure  of  enlarged  lymphatics,  inflamma- 
tion of  parts  of  the  cardiac  plexus,  with  changes  in  the  coronary 
arteries,  seem  to  be  most  constant." 

Symptoms.  A  paroxysmal  affection,  the  attacks  occurring  irreg- 
ularly ;  in  the  interval  entire  absence  of  symptoms,  or  the  symptoms 
of  the  organic  disease  causing  the  paroxysms. 

"  The  patient  suddenly  sits  up  in  his  bed  ;  with  a  cry  of  horror  in- 
dicates the  sense  of  pain  at  the  prjccordium.  The  pain  is  of  great 
intensity,  but  is  of  a  cold  and  sickening  character;  the  chest  is  fixed, 
the  breathing  quickened,  and  the  hand  placed  over  the  pr;ccordium 
finds  that  the  heart's  action  is  slight  and  enfeebled.  The  face  wears 
a  look  of  horror,  pale  and  slightly  leadened ;  a  cold  sweat  breaks  out 
upon  the  forehead  ;  worse  than  the  pain  is  the  feeling  of  fearful  sick- 
ness and  depression.  The  poor  patient  gasps,  '  I  shall  die  !  I  shall 
die  !  '  and  sometimes  his  short  but  concentrated  sufferings  in  a  few 
moments  end  in  death"  (Sansom).  The  attack  ends  suddenly  with 
vomiting,  or  great  flow  of  urine. 

The  unpleasant  sensations  of  these  patients  during  an  attack,  and 
the  nervous  disorder  associated  with  it,  slowly  bring  about  a  mental 
change.  They  are  depressed  and  gloomy,  sometimes  suicidal,  and 
often  develop  epilepsy. 

Attacks  of  angina  in  nervous  women  and  children,  the  hysterical 
or  pseudo-anginal  attacks,  come  on  gradually  with  distention  of  the 
abdomen,  eructations  of  gases,  excessive  restlessness,  flushed  face, 
irritable  pulse,  diffused  praecordial  pain,  and  general  hysterical 
phenomena. 

In  a  few  cases  the  pain  is  absent,  but  all  other  symptoms  are 
present — the  "  angina  sine  dolore  "  of  Gairdner.  Balfour  claims  that 
pain  is  not  an  essential  part  of  the  disease.  He  has  probably  never 
experienced  an  attack  of  true  angina  pectoris. 

Diagnosis.  The  points  to  be  remembered  are  that  the  attacks 
are  always  paroxysmal,  with  long  or  short  intervals,  the  patient  hav- 
ing a  sense  of  coldness,  and  frequently  a  cold  sweat,  the  heart's 
action  not  increased,  the  chest  fixed,  and  the  breathing  slow. 


DISEASES   OF   THE  CIRCULATORY   SYSTEM.  395 

Prognosis.  True  angina  pectoris  is  unfavorable,  the  patient, 
sooner  or  later,  either  succumbing  during  the  paroxysm  or  from 
exhaustion,  the  result  of  the  cardiac  changes. 

Pseudo-angina  is  always  favorable. 

Treatment.  During  the  interval  between  the  attacks  an  attempt 
should  be  made  to  remove  the  exciting  cause  or  diminish  its  predis- 
posing influence. 

For  the  organic  form,  no  one  remedy  is  comparable  with  a  long 
course  of  polassii  iodidum,  gr.  x-xx  (0.6-1.3  Grn.),  three  times  daily, 
as  the  frequency  and  intensity  of  the  attacks  are  often  diminished 
and  a  fair  number  of  cases  are  retarded,  proving  the  axiom,  "  the 
iodides  are  the  digitalis  of  the  arteries." 

The  efficacy  of  the  iodides  is  greatly  enhanced  and  the  course  of  the 
disease  favorably  influenced  by  adding  full  doses  oi  nifro  glycerinum. 

For  the  nervous  form,  all  violent  emotions  and  active  physical  ex- 
ercise are  to  be  avoided,  the  diet  regulated,  and  the  excretions  watched. 
Among  the  drugs  that  are  useful  are  ferrum,  arsenicum,  strychnina, 
phosphorus,  and  zincutn.  If  the  cardiac  action  be  weak,  use  stro- 
phanthus.  Trousseau  urges  the  administration  of  belladontta  in 
continuous  small  doses,  on  the  ground  of  the  analogy  of  the  affection 
to  epilepsy.  Quain  states  that  a  continuous  current,  the  positive  pole 
on  the  sternum  and  the  negative  pole  on  the  lower  vertebrae,  lessens 
the  severity  and  frequency  of  the  anginal  paroxysms. 

For  the  attack,  prompt  relief  follows  the  use  of  amyl  nitras,  TTLiij-v 
(0.2-0.3  Cc),  inhaled  at  the  instant,  or  morphin(z  sulphas,  gr.  %-% 
(0.016-0.032  Gm.),  to  which  may  be  added  with  advantage  atropines 
sulphas,  gr.  ^^  (0.00065  Gm.),  hypodermically,  or  nitro-glycerinum, 
gr.  -^^Q  g'^Q  (0.00065-0.0013  Gm.),  every  hour  or  two.  In  many  cases 
the  use  of  gr.  -^^  (0.00065  Gm.)  of  this  powerful  drug,  three  or  four 
times  a  day  for  a  long  time,  lessens  not  only  the  frequency,  but  the 
severity  of  the  paroxysms.  Chlorodyne,  Tr\,x-xv  (0.6-1  Cc),  repeated, 
often  affords  relief.  Chloroformtnn  has  proven  prompt,  efficient, 
and  harmless  administered  as  suggested  by  Balfour — viz.,  "a  half 
drachm  (2  Cc.)  is  poured  upon  a  sponge  at  the  bottom  of  a  wide- 
mouthed  bottle,  from  which  the  patient  may  breathe  ad  libitum^ 
Dr.  William  Evans  recommends  spartei7tce  sulphas,  gr.  %  (0.016 
Gm.)  three  times  daily,  between  attacks,  to  prolong  the  interval  and 
lessen  the  severity  of  the  paroxysms. 

Great  care  must  be  exercised  with  the  diet  that  flatulency  and  con- 
stipation do  not  occur. 


3%  PRACTICE    OF    MEDICINE. 


ARTERIO-SCLEROSIS. 


Synonyms.  Atheroma;  arterio-capillary  fibrosis  (Gull  and  Sut- 
ton) ;  endarteritis  chronica  deformans  (Virchow). 

Definition.  A  chronic  degenerative  and  inflammatory  disease 
of  the  vascular  system,  resulting  in  an  over^^'rowih  of  the  con- 
nective tissues  of  the  arteries,  followed  by  calcareous  deposits.  The 
changes  may  extend  to  the  capillaries  and  veins.  As  a  result  of  the 
impairment  of  the  arterial  circulation,  occur  fibroid  degenerations  in 
other  organs,  resulting  in  loss  of  elasticity  in  the  walls  of  the  vessels, 
increase  of  arterial  tension,  narrowing  of  the  calibre  of  smaller 
arteries,  and  impairment  of  the  nutrition  of  the  organs  supplied. 

Causes.  Old  age, .as  "longevity  is  a  vascular  question,  and  has 
been  well  expressed  in  the  axiom  that  "a  man  is  only  as  old  as  his 
arteries  "  (Osier).  Heredity  is  a  factor,  as  arterial  degenerations  occur 
in  some  families  at  a  very  early  age — thirty  to  forty  years.  Alcoholism, 
syphilis,  and  other  excesses  predispose  to  arterial  changes.  Lead- 
poisoning,  diabetes,  malaria,  gout,  and  rheumatism.  Chronic  nephri- 
tis.    More  common  in  men  than  in  women. 

Pathological  Anatomy.  The  atheromatous  changes  are  most 
frequent  in  the  aorta.  Rokitansky  gives  the  relative  order  in  which 
atheromatous  degenerations  occur  as  follows,  aorta,  splenic,  femoral, 
iliac,  coronary  arteries  of  the  heart,  arteries  of  the  brain,  uterine,  sub- 
clavian, brachial,  ulnar,  and  radial. 

The  internal  surface  of  the  affected  vessels  is  irregularly  thickened 
with  either  gelatinous  and  translucent,  or  dense  and  fibrous,  or 
calcareous  deposits  or  products.  If  the  calcification  is  extensive,  the 
vessel  is  changed  into  a  hard,  stiff  tube.  Often  the  surface  of  the 
thickening  or  deposit  is  destroyed,  presenting  the  so-called  "ather- 
omatous ulcers,"  which  may  be  covered  with  masses  of  thrombus. 

The  above  conditions  are  the  result  of  inflammatory  change  in  the 
intima  of  the  affected  vessel.  This  appears  three  or  four  times  as 
thick  as  normal,  due  to  the  swelling  of  its  elements,  the  new  growth 
of  connective  tissue  and  the  deposit  of  round  cells.  Fatty  degenera- 
tion of  the  inflammatory  products  results. 

The  result  of  the  changes  in  the  arteries  is  a  loss  of  their  elasticity, 
thus  hindering  the  propulsion  of  the  blood  current  and  raising  the 
arterial  tension,  leading  to  hypertrophy  of  the  left  ventricle.     The 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  397 

changes  finally  involving  the  coronary  arteries  lead  to  alterations  in 
the  myocardium.  If  the  intima  of  the  smaller  vessels  be  involved, 
the  blood  current  to  the  organs  supplied  is  lessened,  resulting  in  a 
disturbance  of  their  nutrition. 

Symptoms.  Not  always  apparent.  The  symptoms  vary  with 
the  arteries  involved  and  the  organs  whose  blood  supply  is  lessened 
or  cut  off. 

Cardiac  hypertrophy  from  the  increased  resistance  to  the  arterial 
circulation. 

The  peripheral  arteries  involved  in  the  atheromatous  changes  can 
be  determined  by  palpation,  they  having  a  hard,  bony  feeling,  much 
like  a  whip  cord. 

Attacks  of  vertigo,  pseudo-apoplectic  attacks,  or  spells  of  uncon- 
sciousness in  the  aged  or  those  having  superficial  hardened  arteries 
are  generally  due  to  changes  in  the  cerebral  vessels.  Evidences  of 
myocarditis  and  angina  pectoris  point  to  atheroma  of  the  aorta  and 
coronary  arteries.  Gangrene  of  the  extremities  in  the  old — senile 
gangrene — point  to  atheroma  or  thrombi,  the  result  of  the  fibrosis. 

Palpation.  Hard,  superficial  arteries,  those  at  the  wrist  feeling 
like  a  string  of  beads,  pulsating.  The  cardiac  impulse  is  forcible  in 
the  early  stages. 

Percussion.  Increased  prascordial  dullness,  particularly  over  the 
left  ventricle. 

Auscultation.  In  the  early  stages  the  first  sound  of  the  heart 
is  prolonged,  the  second  sound  accentuated  over  the  aortic  cartilage. 
As  the  heart  dilates  and  the  walls  become  diseased,  the  sound  be- 
comes feeble  and  often  irregular  and  intermittent. 

Diagnosis.  Only  determined  by  a  close  study  of  the  various 
symptoms  and  sequels. 

Prognosis.     Incurable, 

Treatment.  Regulate  the  manner  of  living  and  the  diet.  Pre- 
vent constipation,  and  torpid  liver  and  kidneys.  No  remedy  can 
remove  the  fibroid  changes,  but  a  very  considerable  experience  has 
convinced  me  that  much  comfort  and  prolongation  of  life  follows  the 
constant  use  several  times  a  day  for  months  and  years  of  nitro-glyc- 
erinum,  gr.  yj^  (0,00065  Gm.),  and  long  courses  oi potassiiiodidntn. 


398  PRACTICE    OK    MEDICINE. 


ANEURISM  OF  THE  AORTA. 

Varieties.  I.  Aneurism  of  the  arch  of  the  aorta.  II.  Aneurism 
of  the  thoracic  aorta.     III.  Aneurism  of  the  abdominal  aorta. 

The  arch  of  the  aorta  is  divided  by  Gray  into  three  parts — the  as- 
cending, the  transverse,  and  the  descending. 

The  ascending  portion  is  two  inches  in  length,  arising  from  the  left 
ventricle,  on  a  level  with  the  lower  border  of  the  left  third  costal 
cartilage,  behind  the  left  edge  of  the  sternum.  It  ascends  obliquely 
upward  to  the  right  to  the  upper  border  of  the  right  second  costo- 
sternal  articulation.  The  transverse  portion  commences  at  the  upper 
border  of  the  right  second  sternal  articulation,  and,  arching  to  the  left 
and  forward,  passes  in  front  of  the  trachea  and  oesophagus  to  the  left 
of  the  third  dorsal  vertebra.  The  descending  portion  extends  down- 
ward to  the  left  side  of  the  fourth  dorsal  vertebra. 

The  thoracic  aorta  extends  from  the  left  lower  border  of  the  fourth 
dorsal  vertebra,  and  ends  in  front  of  the  body  of  the  twelfth  dorsal 
vertebra,  at  the  aortic  opening  in  the  diaphragm. 

The  abdominal  aorta  begins  at  the  aortic  opening  in  the  diaphragm, 
descends  a  little  to  the  left  side  of  the  vertebral  column,  and  termi- 
nates over  the  body  of  the  fourth  lumbar  vertebra,  where  it  divides  into 
the  two  common  iliac  arteries. 

Definition.  A  circumscribed  dilatation  of  some  portion  of  the 
aorta,  the  result  of  disease  of  the  vessel  wall  weakening  its  resistance 
to  the  blood  pressure. 

Causes.  Those  causing  arterio-sclerosis  are  the  chief  causes. 
Exertion  is  an  exciting  cause.  Aneurisms  occur  in  early  middle  life 
rather  than  in  old  age,  when  the  force  of  the  heart  has  decreased. 
More  common  in  men  than  in  women. 

Pathological  Anatomy.  All  aneurisms  may  be  divided  into 
two  classes,  dissecting  and  circumscribed. 

Dissecting  Aneurism — false  aneurism — is  the  result  of  falty  changes 
in  the  internal  and  middle  coats  of  the  artery.  The  shape  may  be 
sacculated,  fusiform,  or  cylindrical.  A  disease  of  the  aged.  Cir- 
cumscribed Aneurism  may  be  true  or  false,  depending  on  the  rupture 
of  the  walls  or  not.  It  is  a  disease  of  middle  life  or  under.  Most 
frequent  in  men,  usually  a  true  dilatation.  Syphilis  is  a  very  fre- 
quent cause. 


DISEASES   OF  THE  CIRCULATORY   SYSTEM.  399 


ANEURISM  OF  THE  ARCH. 

Symptoms.  The  onset  is  usually  gradual,  with  evidences  of 
arterio-sclerosis  and  failing  health. 

Pain,  either  paroxysmal  or  constant,  is  a  continuous  symptom,  with 
increasing  dyspncea.  The  difficulty  in  breathing  may  be  constant 
with  exacerbations,  or  it  may  be  remittent.  Rarely  dysphagia  occurs. 
A  slight  congh  from  pressure  on  the  laryngeal  nerve,  with  more  or 
less  alterations  in  the  voice,  may  be  present.  Th.^  pupils  are  dilated 
or  contracted  or  are  irregular,  in  some  cases  due  to  pressure  on  the 
sympathetic  nerve.  There  is  a  gradual  loss  of  flesh,  disorders  of  the 
circulation,  and  a  careworn  expression  of  the  face. 

Inspection.     Negative  until  the  appearance  of  a  pulsating  tumor. 

Palpation.  A  pulsation  over  the  tumor,  expansile  in  character 
(Corrigan's  sign). 

If  the  aneurism  is  situated  at  the  transverse  portion  of  the  arch,  the 
left  pulse  and  the  left  carotid  are  smaller  and  weaker  than  those  on 
the  right  side.  Tracheal  tugging  is  a  diagnostic  sign  (Page).  "  Place 
the  patient  in  the  erect  position,  with  his  mouth  closed  and  chin 
elevated  to  the  fullest  extent.  Then,  on  grasping  the  cricoid  cartilage 
between  the  fingers  and  thumb  and  making  gentle  traction  upward, 
the  pulsations  of  dilated  aorta  or  aneurism,  if  any  exist,  will  be  dis- 
tinctly felt,  in  most  cases  transmitted  through  the  trachea  to  the  hand." 

Percussion.  Dullness,  the  extent  depending  on  the  size  of  the 
tumor.  Dullness,  other  than  cardiac,  across  the  sternum  is  diagnostic 
of  a  mediastinal  tumor. 

Auscultation.  Over  the  tumor  a  murmur  or  bruit  is  usually 
heard,  synchronous  with  the  first  sound  of  the  heart.  It  is  louder 
than  the  systole,  lower  in  pitch,  and  of  a  blowing  character. 

Diagnosis.  If  the  tumor  can  be  seen  or  felt,  the  diagnosis  is 
made,  its  location  being  determined  by  a  study  of  the  physical  signs. 


ANEURISM   OF   THE   THORACIC   AORTA. 

Symptoms.  The  most  constant  symptom  is  deep-seatedthoracic 
pain,  constant  or  paroxysmal.  Dysphagia  is  a  frequent  condition. 
There  is  seldom  dyspnoea,  and  alteration  of  voice  and  pupils  does 
not  occur. 


400  PRACTICE    OF    MEDICINE. 

Physical  s/jpts  are  usually  wanting,  and  the  diagnosis  is  rarely 
made  during  life. 

I  have  seen  three  cases  in  which  the  only  symptoms  the  patients 
complained  of  were  pain  of  a  deep-seated  and  boring  character  in  the 
left  shoulder,  associated  with  a  feeling  of  general  fatigue.  Death 
ensued  in  each  of  the  three  cases  suddenly  by  a  frightful  hemorrhage 
from  the  mouth,  death  occurring  in  a  few  moments,  and  an  autopsy 
revealed  a  thoracic  aneurism  pressing  deeply  in  the  upper  left  pul- 
monary lobe  the  size  of  a  lemon,  which  had  suddenly  ruptured. 


ANEURISM   OF   THE   ABDOMINAL  AORTA. 

Symptoms.  The  chief  and  most  constant  symptom  is  pain  at  a 
circumscribed  spot  in  the  abdomen,  or  rarely  diffused  over  the 
abdomen.  Other  symptoms  depend  upon  the  location  of  the  aneurism, 
as  they  are  the  result  of  pressure.     There  is  a  gradual  loss  of  health. 

Inspection.  Usually  negative  unless  the  aneurism  reach  an 
enormous  size. 

Palpation.  A  pulsating  tumor  in  the  abdomen  to  the  left  of  the 
median  line.  The  pulsation  is  synchronous  with  the  first  sound  of 
the  heart,  and  is  expansile  (Corrigan's  sign)  in  character. 

Percussion.  Dullness  may  be  elicited  if  the  tumor  is  large  and 
the  abdomen  emaciated. 

Auscultation.    Rarely  a  murmur  or  bruit  is  heard,  systolic  in  time. 

Diagnosis.  Abdominal  aneurism  and  pulsating  abdominal  aorta 
may  be  mistaken  for  each  other.  The  point  of  difference  is,  in  the 
aneurism,  the  presence  of  the  tumor  with  an  expansile  pulsation, 
while  in  pulsating  abdominal  aorta,  the  beating  is  like  a  pulsating 
cord,  an  up-and-down  movement,  not  expansile.  The  condition  of 
the  patient  is  also  important ;  aneurism  in  males,  at  middle  life,  with 
changes  in  the  vessels ;  abdominal  pulsation  occurring  in  nervous 
women  or  effeminate  men. 

Tumors  located  over  the  abdominal  aorta  may  give  rise  to  an  ap- 
parent pulsation,  causing  them  to  be  mistaken  for  an  aneurism.  The 
rule  is,  in  all  cases  of  abdominal  pulsation,  to  place  the  patient  in  the 
knee-chest  position  ;  if  the  tumor  is  aneurismal,  the  expansile  pulsa- 
tion continues  ;  if  not  an  aneurism  but  a  cancer,  impacted  faeces,  ot 
other  tumor,  the  pulsation  at  once  ceases. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  401 

ProgxiGsis  of  Aortic  Aneurisms.  Unfavorable.  The  duration 
of  life  after  the  development  of  the  aneurism  is  from  one  to  four  years. 

Treatment.  A  persistent  effort  should  always  be  made  to  pro- 
mote clotting  in  the  sac  and  the  contraction  of  the  ttwior. 

The  so-called  Tufnell's  method  is  the  most  successful  for  this  pur- 
pose, its  aim  being  to  diminish  the  force  and  rapidity  of  the  circula- 
tion, and,  if  possible,  to  increase  the  fibrinous  deposit.  Its  essential 
element  is  absolute  rest  of  mind  and  body,  and  a  restricted  diet ;  the 
patient  is  kept  absolutely  in  bed  day  and  night  for  at  least  three 
months,  and  placed  on  the  following  diet;  Breakfast — two  ounces  of 
bread  with  butter  and  two  ounces  of  milk ;  dinner — two  or  three 
ounces  of  bread,  same  amount  of  meat,  and  two  to  four  ounces  of 
milk  or  claret  wine;  supper — two  ounces  of  bread  with  butter  and  two 
ounces  of  milk.  At  the  same  time  potassii  iodidum  is  administered  in 
increasing  doses  to  the  physiological  limit. 

Galvano-puncture  is  said  to  do  good  in  some  cases ;  two  needles 
inserted  into  the  aneurism  are  connected  with  the  poles  of  a  galvanic 
battery,  and  a  weak  current  is  passed  through  the  tumor. 

The  various  symptoms  are  to  be  met  with  their  appropriate  reme- 
dies, always  having  in  mind  the  condition  of  the  arterial  wall  allowing 
the  rupture  and  dilatation. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  diseases  of  the  nervous  system  will  be  described  under  the 
following  headings  : 

I.  Diseases  of  the  cerebral  membranes.  II.  Diseases  of  the 
cerebrum.  III.  Diseases  of  the  spinal  cord.  IV.  Diseases  of  the 
nerves.     V.  General  or  nutritional  diseases.     VI.  Mental  diseases. 


26 


402  PRACTICE    OK    MEDICINE. 


DISEASES   OF   THE   CEREBRAL   MEM- 
BRANES. 


The  brain  is  invested  with  two  membranes — the  dura  mater  and  the 
pia  mater,  or  pia-arachnoid. 

The  dura  lines  the  interior  of  the  skull,  and,  in  addition,  supports 
and  protects  the  brain.  Theyiz/.r  is  an  extended  process  of  the  dura 
which  extends  into  the  longitudinal  fissure  ;  the  tentorium  is  a  process 
of  the  dura  separating  the  cerebrum  and  the  cerebellum  ;  \.\\cfa/cula 
is  a  process  of  the  dura  extending  between  the  two  hemispheres  of 
the  cerebellum. 

The  blood  supply  for  the  dura  is  from  the  anterior,  middle,  and 
posterior  meningeal  arteries.  The  middle  meningeal  or  medidural 
artery,  a  branch  of  the  internal  maxillary,  is  the  largest  of  the  three, 
and  is  the  vessel  usually  involved  in  meningeal  hemorrhage. 

The  nerve  supply  (a  mooted  question)  is  undoubtedly  received 
from  the  fifth  or  trigeminus  pair  of  cranial  nerves,  irritation  of  which 
nerve  supply  may  produce  hyperesthesia, pain,  reflex  motor,  and  vaso- 
motor disturbances  (Duret).  The  pia  (which  includes  the  arachnoid, 
after  the  suggestion  of  Tuke,  and  which  Mills  calls  the  arachnopia, 
or  pia  arachnoid)  is  composed  of  two  layers — the  visceral  layer  and 
the  parietal  layer.  This  membrane  is  a  vascular  network  held  by 
connective  tissue.  The  visceral  \?\.y&r  of  the  pia  (formerly  known  as 
the  pia  alone)  closely  invests  the  brain  everywhere,  dipping  into 
the  fissures  and  into  the  ventricles.  The  parietal  layer  (formerly 
known  as  the  arachnoid)  closely  covers  the  dura  in  all  its  parts. 

The/w  arachnoid  IS  the  nutritive  covering  of  the  brain,  supplying 
a  considerable  section  with  blood.  The  vessels  of  the  pia  lie  on  the 
surface  and  are  encased  in  perivascular  sheaths  composed  of  the 
denser  portions  of  the  membrane.  These  perivascular  spaces  are  the 
lymph-canals  accompanying  the  blood-vessels  into  the  brain-sub- 
stance and  communicating  with  the  subarachnoid  spaces  or  cisterns. 

The  nerve  supply  of  iht  pia  arach?ioid\s  still  in  dispute,  the  mem- 
brane being  generally  considered  without  sensation.  This  is  proba- 
bly an  error. 


DISEASES   OF  THE   CEREBRAL   MEMBRANES.  403 

The  Pacchionian  granulations  are  always  present  in  abundance 
"  on  the  outside  of  the  dura,  on  its  inner  surface,  on  the  arachnopia, 
and  within  the  superior  longitudinal  sinus  and  the  parasinoidal  spaces, 
or  lacs  sanguinis.  They  often  indent  the  calvarium,  and  in  rare 
instances  they  penetrate  it.  It  is  generally  conceded  that  they  are 
enlargements  of  the  normal  villi  or  tuft-like  elevations  of  the  parietal 
layer  of  the  pia  (arachnoid).  Repeated  attacks  of  meningeal  hyper- 
semia  probably  assist  in  their  development"  (Mills). 


PACHYMENINGITIS. 

Synonyms.     Meningitis ;  haematoma  of  the  dura  mater. 

Definition.  Inflammation  of  the  dura  mater ;  when  the  external 
layer  is  primarily  involved,  it  is  termed  pachymeningitis  externa; 
when  the  internal  layer  is  primarily  involved,  it  is  termed  pachyfnen- 
ingitis  interna. 

Causes.  Pachymeningitis  externa  is  a  surgical  malady,  resulting 
from  fractures,  penetrating  wounds,  and  other  injuries  of  the  skull. 

Pachymeningitis  interna  is  due  to  blows  upon  the  head  without 
injury  to  the  skull,  chronic  alcoholism,  scurvy,  Bright's  disease,  tuber- 
culosis, and  syphilis.  Chronic  internal  otitis  and  suppurative  inflam- 
mation of  the  orbit  may  cause  it,  and  also  inflammation  in  the  venous 
sinuses  the  result  of  a  thrombus  undergoing  suppurative  changes. 
Following  erysipelas,  sun-stroke,  and  gout  are  recorded  causes. 

Pathological  Anatomy.  Pachymeningitis  interna.  Hyper- 
aemia  of  the  membrane,  followed  by  an  exudation  which  develops 
into  a  membranous  new  formation,  containing  a  great  number  of 
vessels  of  considerable  size,  but  having  very  thin  walls.  Hemor- 
rhages from  these  new  vessels  are  of  frequent  occurrence,  which  in- 
crease the  size  and  thickness  of  the  neo-membrane. 

The  usual  position  of  the  neo-membrane  or  new  formation  is  on 
the  upper  surface  of  the  hemispheres,  extending  downward  toward 
the  occipital  lobe.  The  changes  in  the  adjacent  portion  of  the  brain 
are  dependent  on  the  size  and  thickness  of  the  neo-membrane. 
Bartholow  observed  a  case  in  which  the  "  cyst "  was  half  an  inch  in 
thickness  at  its  thickest  part,  and  it  depressed  the  hemisphere  corre- 
spondingly, the  convolutions  being  flattened,  the  sulci  almost  obliter- 
ated, and  the  ventricle  lessened  one-half  in  size. 


404  PRACTICE    OF    MEDICINE. 

In  pachymeningitis  syphilitica,  the  pathological  lesion  is  in  the  form 
of  gummatous  tumors  or  masses  which  may  degenerate  and  become 
either  cheesy  masses  or  be  converted  into  a  purulent  looking  fluid. 

In  old  age  the  dura  mater  becomes  thick,  cartilaginous,  and  of  a 
dull  white  color.     The  sheaths  of  the  arteries  are  also  thickened. 

Symptoms.  Very  obscure ;  principally  those  of  cerebral  pres- 
sure. Cases  of  persistent  headache,  vertigo,  photophobia,  anorexia, 
insomnia,  gradual  impairment  of  intellect  and  locomotion,  followed 
by  delirium,  and  convulsions  and  coma,  or  by  apoplectic  attacks  and 
paralysis,  occurring  in  the  aged,  or  those  in  whom  some  one  of  the 
causes  of  the  affection  are  present,  an  inflammation  of  the  dura  mater 
may  be  suspected.   Epileptic  attacks  (dural  epilepsy)  sometimes  occur. 

Circumscribed  painful  oedema  behind  the  ear  and  less  fullness  of 
the  jugular  of  the  corresponding  side,  sh^  phlegmasia  alba  dolens  en 
jniniature  of  Griesinger,  are  indicative  of  thrombosis  in  the  transverse 
sinus,  as  was  first  shown  by  Virchow. 

Diagnosis.  Always  problematical,  as  the  symptoms  are  masked 
and  so  obscure  that  a  positive  diagnosis  is  impossible.  In  very  many 
instances  the  condition  was  not  discovered  until  an  autopsy. 

Prognosis.  Most  unfavorable  for  either  forms,  although  the 
course  of  the  malady  is  usually  slow.  Surgical  treatment  in  traumatic 
cases  offers  some  hope. 

Treatment.  Pachymeningitis  externa  is  to  be  treated  surgically. 
Trephining  is  indicated  in  some  cases.  It  is  claimed  that  benefit 
has  followed  a  thorough  course  o{  potassii  iodidum.  In  the  great 
majority  of  cases,  however,  all  that  can  be  done  is  to  treat  symp- 
toms. 


ACUTE  LEPTOMENINGITIS. 

Synonyms.      Acute  meningitis;  cerebral  fever;  arachnitis. 

Definition.  An  acute  exudative  inflammation  of  the  cerebral //a 
mater  and  arachnoid  membranes  (pia  arachnoid,  or  arachnopia), 
usually  limited  to  the  convexity  of  the  cerebrum  ;  characterized  by 
fever,  vomiting,  headache,  delirium,  and  followed  by  symptoms  of 
general  collapse. 

Causes.  During  the  course  of  the  acute  infectious  diseases  ;  ery- 
sipelas; associated  with  or  a  sequela  of  influenza  and  typlioid  fever. 
Cerebral  overwork ;  prolonged  wakefulness ;  acute  alcoholism  ;  ex« 


DISEASES   OF  THE  CEREBRAL   MEMBRANES.  405 

posure  to  the  sun  ;  syphilis  ;  blows  on  the  head  ;  disease  of  the  internal 
ear  ;  secondary  to  diseases  of  serous  membranes.  Most  frequent  in 
early  adult  life  and  in  young  children,  and  in  males  rather  than 
females. 

"  The  micro-organisms  found  in  meningitis  are  the  pneumococcus, 
streptococcus  pyogenes,  intracellular  diplococcus,  the  pneumo-bacil- 
lus,  and  a  bacillus  resembling  that  of  typhoid  fever  "  (Dana). 

Pathological  Anatomy.  The  inflammatory  changes  may  be 
limited  either  to  the  convexity  or  to  the  base  of  the  brain,  but  more 
frequently  both  portions  are  involved. 

Intense  hypercemia  of  both  membranes,  followed  by  a  purulent  and 
fibrinous  exndaiion.  The  ventricles  may  be  filled  with  fluid,  com- 
pressing and  flattening  the  convolutions. 

In  twenty-five  post-mortem  examinations  at  the  Philadelphia  Hos- 
pital a  meningo-encephalitis  was  present  in  fourteen. 

Symptoms,  Keeping  in  mind  the  anatomy  of  the  cerebral 
membranes  and  the  extent  of  surface  that  may  be  involved  in  an 
inflammation,  it  will  be  seen  how  varied  may  be  the  symptoms  of 
leptomeningitis. 

Prodromes :  Headache,  vertigo,  cerebral  vomiting,  more  or  less 
feverishness,  continuing  from  a  few  hours  to  one  or  two  days,  when 
occurs  the 

Stage  of  Invasion :  Onset  with  a  chill,  high /ever,  103°- 104° ;  a.  pulse 
\00-\20;  face  flushed  v^'vCa.  congested  eyes ;  severe  headache,  most 
intense  and  continuous ;  ringing  in  the  ears,  photophobia,  vertigo, 
the  nausea  aggravated  ;  projectile  vomiting,  with  delirium  ;  general 
hyperesthesia  to  the  touch. 

Stage  of  Excitation  :  General  sensibility  of  the  body,  increased  with 
sensitiveness  to  light  and  acuteness  of  hearing;  deliriimt  furious, 
often  resembling  mania ;  continual  jerking  of  the  limbs,  oscillations 
of  the  eyeballs  (nystagmus),  twitching  of  the  muscles  of  the  face, 
followed  by  powerful  contractions  of  the  flexor  muscles,  even  to  the 
extent  of  opisthotonos,  and  in  children  convulsions  ;  coated  tongue, 
constipation  and  retracted  abdomen.  Duration,  from  one  day  to  a 
week  or  two. 

The  finger  drawn  across  the  surface  leaves  a  red  line,  the  tache 
cerebrale. 

Stage  of  Depression  or  Collapse ;  the  patient  gradually  becomes 
more  quiet,  the  delirium  subsiding,  as  well  as  the  muscular  agitation  ; 


406  PRACTICE    OF    MEDICINE. 

somnolence  develops  passing  into  coma,  at  times  temporary  conscious- 
ness, coma  soon  following  again  ;  pulse  irregular  and  slow, yi'Trr less; 
various  palsies,  such  as  strabismus,  ptosis,  pupils  uninfluenced  by  light, 
mouth  drawn  to  one  side,  and  urine  and  faeces  involuntarily  discharged. 
Death  following  either  by  convulsions  or  by  deepening  coma  with 
cyatwsis. 

Diagnosis.  The  characteristic  symptoms  indicating  the  existence 
of  acute  leptomeningitis  are  headache,  voviiting,  fever,  and  delirium, 
all  developing  rather  rapidly.  The  headache  is  most  persistent,  and 
the  vomiting  not  due  to  gastric  trouble.  The  absence  of  any  one  of 
the  four  characteristic  symptoms  named  above  does  not  prove  the 
absence  of  leptomeningitis,  nor  does  the  combination  of  delirium  and 
fever  alone  determine  the  presence  of  meningeal  disease. 

Cerebrospinal  fever  closely  resembles  acute  leptomeningitis,  the 
points  of  distinction  between  which  are  the  first  named  occurring 
epidemically,  associated  with  marked  spinal  symptoms  and  an 
eruption. 

Meningitis  and  abscess  of  the  brain  are  apt  to  be  mistaken  for  each 
other,  the  differential  diagnosis  being  pointed  out  in  the  latter  disease. 

The  cerebral  symptoms  of  rheumatism  are  differentiated  from  idio- 
pathic meningitis  by  the  association  of  the  joint  trouble. 

Cerebral  syviptoms  of  typhoid  and  typhus  fever  have  a  close  resem- 
blance to  idiopathic  meningitis,  and  are  only  determined  by  a  study 
of  the  clinical  history. 

In  acute  uramia  the  face  is  turgid,  oedematous,  with  puffiness  of 
the  eyelids  ;  in  leptomeningitis  the  face  is  pale  and  no  cedema ;  urae- 
mia has  decided  albuminuria;  it  is  slight  or  absent  in  leptomenin- 
gitis ;  leptomeningitis  has  chills  followed  by  fever ;  uraemia  has 
irregular  temperature  record,  rapidly  rising  to  104°  F.-io6°  F.  and 
dropping  to  99°  F.,  to  as  rapidly  rise  again,  and  usually  associated 
with  convulsions. 

In  delirium  tremens  the  delirium  is  a  busy  one,  the  patient  imagin- 
ing persons  and  animals  around  him,  and  is  wild  in  his  gestures  and 
utterances;  the  temperature  is  normal  or  subnormal,  the  skin  wet 
and  clammy.  In  leptomeningitis  the  delirium  is  mild  but  incoherent, 
the  surface  is  hot  and  dry,  and  there  is  severe  vomiting  and  head- 
ache. 

Prognosis.  Not  very  favorable.  If  recognized  early  and  treated, 
a  fair  number  of  recoveries  occur,  but  it  usually  leaves  the  patient 


DISEASES   OF  THE   CEREBRAL   MEMBRANES.  407 

subject  to  attacks  of  epilepsy  or  with  a  persistent  headache,  and  more 
or  less  mental  impairment.  Blindness  and  chronic  internal  hydro- 
cephalus are  rare  results. 

Treatment.  Keeping  in  view  the  course  and  general  prognosis 
of  leptomeningitis,  it  is  questionable  if  any  very  active  medication 
will  abate  the  disease  during  any  stage. 

Bed-rest,  quiet,  in  a  well-ventilated  room,  with  elevation  of  the 
head,  and  the  use  of  a  nutritious  liquid  diet,  with  attention  to  all  the 
secretions,  which  are  markedly  disordered,  and  the  application  of 
cold  to  the  head  for  the  intense  headache,  and  meeting  the  symptoms 
as  they  arise  in  the  different  stages  of  the  disease,  is  the  safer  way  to 
manage  the  majority  of  cases  of  leptomeningitis.  Attempts  at  abort- 
ing the  malady  are  depressing  to  the  patient  in  the  later  periods  of 
the  malady. 

In  vigorous  or  sthenic  cases,  with  high  febrile  reaction  and  exag- 
geration of  the  early  symptoms,  a  more  or  less  vigorous  venesection, 
or  the  use  of  leeches  behind  the  ears,  to  the  temples,  or  in  the  nuchal 
region,  followed  by  the  application  of  (T^/^  and  the  internal  use  of  full 
doses  of  extractuni  ergofce  fliiidufn  every  couple  of  hours,  may  be 
used.  The  cerebral  circulation  may  be  markedly  influenced  by  com- 
pression of  the  carotids. 

For  the  vomiting  use  chloral,  gr.  iij-v  (0.2-0.3  Gm.),  per  mouth,  di- 
luted with  aquae  menthse  f^ss  (15  Cc),  repeated  in  half  hour  and 
p.  r.  n.,  or  by  enema  in  doses  of  gr.  x-xv  (0.6-1  Gm.).  The  most 
refractory  vomiting,  of  whatever  cause,  will  yield  to  a  few  doses  of 
this  drug. 

If  the  disease  show  a  disposition  to  linger,  small  doses  of  hydrargyri 
chloridum  mite  or  poiassiiiodiduin  are  of  benefit. 

Third  stage  :  Free  stimulation,  nutritious  food,  ferri  iodidum,  and 
flying  blisters. 

TUBERCULAR  MENINGITIS. 

Synonyms.     Basilar  meningitis  ;  acute  hydrocephalus. 

Definition.  An  inflammation  of  the  leptomeninges  (soft  mem- 
branes), particularly  the  basal  pia  mater,  attended  with  or  due  to  the 
deposit  of  gray  miliary  tubercle ;  characterized  by  gradual  decline 
of  the  bodily  and  mental  powers. 

Causes.     Usually  a  secondary  affection,  a  sequel  to  tubercular 


40S  PRACTICE    OF    MEDICINE. 

disease  of  some  other  organ.  Most  frequently  occurs  in  children 
between  two  and  six  years  of  age,  although  numerous  cases  are 
reported  occurring  between  twenty  and  thirty  years;  scrofulous  (?) 
diathesis;  inherited  diathesis.  The  "gelatinous  children  of  album- 
inous parents,"  as  the  phrase  goes,  possess  a  special  susceptibility  to 
tubercular  meningitis. 

Pathological  Anatomy.  The  deposition  of  tubercle  usually 
occurs  at  the  base  of  the  brain. 

Depositions  of  grayish-white  granules,  of  a  translucent,  somewhat 
gelatinous  appearance — miliary  tubercle,  are  distributed  along  the  ves- 
sels of  the  pia  mater,  resulting  in  inflammation  and  the  exudation  of 
lymph,  with  the  consequent  thickening  and  opacity  of  the  membranes. 

The  cerebral  tissue  is  not  usually  involved,  although  on  section  the 
lines  indicative  of  blood-vessels  are  very  much  increased  in  number. 
The  ventricles  are  distended  by  a  clear,  or  milky,  or  even  bloody 
serum. 

Tubercular  deposits  occur  in  the  lungs,  intestines,  and,  at  times,  in 
other  organs. 

The  presence  of  the  tubercles  alone  may  give  rise  to  no  symptoms 
until  the  exudative  products  of  the  resultant  inflammation  develop. 

Symptoms.  The  advent  is  either  gradual  and  insidious,  or  with 
convulsions,  in  which  cases  the  after  progress  is  rapid. 

Prodromes :  The  child  grows  irritable,  with  loss  of  appetite,  loss  of 
flesh,  swollen  abdomen,  constipation  alternating  with  diarrhoea, 
irregular  attacks  of  feverishness,  with  attacks  of  grinding  the  teeth 
during  sleep,  or  sleeplessness.  Headache  occurs,  as  shown  by  the 
child,  even  when  at  play,  suddenly  stopping  and  resting  its  head  on 
its  hand  or  on  the  floor.  Duration  of  this  stage  is  from  one  week  to 
a  month  or  two. 

Stage  of  excitation  :  The  onset  is  rather  sudden,  with  obstinate 
vomiting,  severe  headache,  convulsions  ;  fever,  I02°-I03°  in  the  even- 
ing, falling  to  99*^  in  the  morning;  pulse  soft  and  compressible,  with 
irregular  rhythm.  On  drawing  the  finger  nail  lightly  over  the  surface 
a  red  line  results,  "the  cerebral  stain  "  of  Trousseau.  The  symp- 
toms grow  progressively  worse  with  exaltation  (hyperesthesia)  of  the 
special  and  general  senses,  the  least  pinch  or  even  touch  causing 
exquisite  pain  ;  spasmodic  ynovements  of  the  muscles,  with  contraction 
and  rigidity,  at  times  opisthotonos.  Duration  of  this  stage  is  about 
two  weeks  to  a  month. 


DISEASES   OF   THE   CEREBRUM.  409 

Stage  of  depression,  the  result  of  the  pressure  of  the  exudation  ;  the 
pulse  is  slow  and  compressible,  with  irregular  rhythm  ;  temperature 
depressed ;  tendency  to  somnolence  alternating  with  quiet  delirium, 
mental  stupor,  continual  movement  of  the  fingers,  as  in  picking  up 
objects ;  convulsions  from  time  to  time,  strabismus,  oscillation  of  the 
eyeballs  (nystagmus),  followed  by  intervals  of  wakefulness,  when  the 
headache  is  excruciating,  causing  the  peculiar,  unearthly  shrill  cry  or 
shriek,  "the  hydrocephalic  cry,"  associated  with  contraction  of  the 
muscles  of  the  face,  as  if  suffering  were  experienced;  finally  collapse 
occurring  with  the  "  Cheyne-Stokes  "  respiration,  the  coma  deepening, 
followed  by  death,  convulsions  often  ending  the  scene.  Duration, 
from  a  day  or  two  to  two  weeks. 

Diagnosis.  Acute  leptomeningitis  and  tubercular  meningitis 
have  closely  analogous  symptoms  during  the  stage  of  excitation,  but 
the  history  and  clinical  course  of  the  two  maladies  determine  the 
diagnosis. 

Prognosis.  Unfavorable.  Usual  duration,  three  or  four  weeks 
after  fully  developed  prodromes.  If  ushered  in  by  convulsions,  the 
duration  is  shorter. 

Treatment.  Most  unsatisfactory.  No  means  of  retarding  the 
disease.  Treat  symptoms  as  they  develop.  Blisters,  leeches,  active 
purgation,  pustulating  omirnQnts,  potassii  iodidipn,  and  hydrargyrum 
are  all  useless. 

If  the  hereditary  tendency  be  marked,  nutritious  food,  oletim  mor- 
rhucE,ferri  iodidum,  and  quinina  may  somewhat  delay  the  develop- 
ment of  the  affection. 


DISEASES  OF  THE  CEREBRUM. 


To  understand  the  symptoms  in  diseases  of  the  nervous  system,  a 
clear  and  precise  knowledge  of  the  anatomy  and  physiology  is  neces- 
sary. Presuming  this  knowledge,  only  a  very  few  of  the  most  ele- 
mentary facts  will  be  mentioned  before  discussing  diseases  of  the 
brain  and  cord. 


410  PRACTICE    OF    MEDICINE. 

The  ftervg-ce/l'xs  the  real  foundation  of  the  nervous  system.  It  re- 
ceives its  nourishment  from  the  arterioles  and  the  lymphatics,  and  is 
drained  by  the  venules,  as  are  other  tissues,  and  is  supported  by  the 
connective  tissue.  Each  nerve-cell  has  two  processes,  the  axis  cylin- 
der process  and  iht  protoplasmic  process  ;  the  three — the  cell  and  the 
two  processes — are  known  as  the  neurons,  the  nervous  system  being 
made  up  of  neurons.  The  axis-cylinder  processes  conduct  the  nerve 
impressions  or  current  from  the  cells,  and  is  a  continuation  of  the 
axis-cylinder  of  the  nerve.  The  protoplasmic  process  conducts  the 
nervous  current  or  impressions  into  the  cell,  and  it  is  through  these 
processes  and  their  collaterals  that  the  cell  is  brought  into  communi- 
cation with  all  portions  of  the  body.  The  nerve-cells — "the  very 
inner  citadel  of  nervous  life" — are  mainly  set  in  the  gray  matter  of 
the  brain  and  the  spinal  cord,  and  the  axis-cylinder  processes  and 
the  protoplasmic  processes  run  in  bundles  or  collections  in  the  white 
matter  of  the  brain  and  spinal  cord.  The  gray  matter  of  the  brain 
and  spinal  cord,  or  the  nerve-cells,  is  found  chiefly  in  the  cortex  of 
the  cerebrum  and  the  basal  ganglia,  the  cortex  of  the  cerebellum,  in 
the  horns  of  the  spinal  cord  and  the  nuclei  of  the  medulla  oblongata, 
and  all  these  masses  of  gray  matter  or  cells  are  connected  by  nerves, 
or  the  white  matter,  each  protected  by  connective  tissue.  The  cells 
endow  the  nerves  with  their  particular  functions.  A  knowledge  of 
the  physiology  of  the  nervous  system  is  essential  to  understand  the 
functions  of  the  different  masses  of  gray  matter,  or  cells,  and  of  the 
nerves,  or  white  matter. 

Without  a  knowledge  of  the  known  centers  of  "  localization  "  it  is 
impossible  to  interpret  the  symptoms  of  diseases  of  the  nervous 
system. 

A  knowledge  of  the  blood  supply  of  the  brain  is  of  practical  im- 
portance, and  particularly  for  understanding  the  symptoms  and  path- 
ology of  apoplexy  and  cerebral  emboli. 

The  external  carotids  on  each  side  supply  blood  to  the  scalp,  the 
skull,  and  the  dura  mater. 

The  internal  carotid  artery  on  each  side  and  the  vertebral  arteries 
supply  the  brain,  pia  mater,  and  the  eyes. 

The  internal  carotid  arteries  divide  into  the  anterior  cerebral  and 
the  middle  cerebral  arteries. 

The  vertebral  arteries  on  each  side  give  off  the  inferior  cerebellar 
arteries,  and  then  join  and  form  the  basilar  artery,  which  redivides, 


DISEASES   OF  THE   CEREBRUM.  411 

forming  the  two  posterior  cerebral  arteries,  which,  in  turn,  give  off  the 
posterior  communicating  artery.  It  is  the  uniting  of  these  cerebral 
arteries  by  the  anterior  and  posterior  communicating  arteries  that 
forms  the  circle  of  Willis.  From  various  portions  of  the  circle  of 
Willis  and  the  beginnings  of  the  anterior,  middle,  and  posterior  cere- 
bral arteries  are  given  off  six  groups  of  vessels,  which  furnish  the 
blood  supply  to  the  basal  ganglia  and  the  adjacent  white  matter,  from 
which  they  derive  their  name,  "the  central  arteries  of  the  brain." 
The  "  central  arteries  "  given  off  by  the  middle  cerebral  or  Sylvian 
artery  are  of  the  most  importance  to  the  clinician.  They  are  known 
as  the  lenticular-optic  and  the  lenticular-striata  arteries,  and  are 
usually  involved  in  cerebral  hemorrhage. 

The  following  centres  have  thus  far  been  localized  in  the  cortex — 
viz:  the  motor,  vision,  word-deafness,  word-blindness,  aphasia, 
agraphia,  and  muscular  sense  of  pain  and  touch.  The  "  mind  "  centre 
has  been  long  considered  as  located  in  the  frontal  lobe,  anterior  to  the 
motor  area  and  the  third  frontal  convolution,  but  of  late  the  view  is 
growing  that  for  complete  integrity  of  the  mind  the  entire  cortex  must 
be  intact,  although  lesions  of  the  portions  named  produce  mental 
symptoms  only,  while  lesions  of  other  portions  of  the  cortex  cause 
other  disorders  in  which  mental  changes  are  more  or  less  prominently 
observed. 

The  many  symptoms  resulting  from  diseases  of  the  brain  can  be 
placed  in  four  groups  : 

I.  General  symptoms  of  brain  irritation.  2.  General  symptoms  of 
brain  pressure.  3.  Symptoms  of  focal  irritation  or  destruction.  4. 
Symptoms  due  directly  to  the  pathological  process. 

Symptoms  of  brain  irritation,  or  hyperemia,  are ;  headache,  ver- 
tigo, vomiting,  photophobia,  mental  irritability,  insomnia,  fullness  or 
pressure  over  the  brain,  with  scalp  tenderness  and  noises  in  the  ears. 
Rarely  convulsive  symptoms  and  delirium  may  occur. 

Symptoms  of  brain  pressure  are :  headache,  vomiting,  mental  dull- 
ness, and  frequently  some  form  of  paralysis  with  contracted  pupil 
and  finally  coma. 

Focal  lesions  depend  upon  their  character:  if  irritative,  convulsive 
or  spasmodic  phenomena  if  located  in  the  motor  area,  and,  if  decided 
pressure  or  destructive  lesions,  paralysis,  such  as  hemiplegia  and 
aphasia. 

The  symptoms  of  brain  lesions  due  to  the  pathological  process  itself 


412  PKACTICE    OF    MEDICINE. 

have  few  if  any  paiticular  symptoms  other  than  those  due  to  the  loca- 
tion except  in  abscess  or  gummata,  when  the  constitutional  symptoms 
of  suppuration,  such  as  chills,  fever,  sweats,  and  prostration,  are 
added  to  other  brain  symptoms. 


CONGESTION  OF  THE  BRAIN. 

Synonyms.     Cerebral  hyperaemia;  cerebral  congestion. 

Definition.  An  abnormal  fullness  of  the  vessels  (capillaries)  of 
the  brain  :  Active,  when  arterial  fullness  ;  passive,  when  venous  full- 
ness ;  characterized  by  headache,  vertigo,  disorders  of  the  special 
senses,  and,  if  the  hyperasmia  be  decided,  convulsions. 

Causes.  Active.  Increased  cardiac,  action,  the  result  of  hyper- 
trophy of  the  left  ventricle  ;  general  plethora  ;  excesses  in  eating  and 
drinking;  acute  alcoholism;  sunstroke;  prolonged  mental  labor; 
diminished  amount  of  arterial  blood  in  other  parts,  the  result  of 
the  compression  of  the  abdominal  aorta  or  ligation  of  a  large 
artery,  or  the  suppression  of  an  habitual  bleeding  hemorrhoid,  are 
examples. 

Passive.  Dilatation  of  the  right  heart ;  pressure  upon  the  veins 
returning  the  cerebral  blood. 

While  congestion  of  the  brain  is  not  so  frequent  as  was  once  sup- 
posed, the  view  that  it  cannot  occur  is  disproven  by  the  results  fol- 
lowing the  inhalation  of  a  full  dose  of  amyl  nitris.  The  relief  of  head 
symptoms  after  a  free  epistaxis  and  the  distress  resulting  if  it  does 
not  occur  is  another  instance. 

Pathological  Anatomy.  The  post-mortem  appearances  are  : 
Overloading  of  the  venous  sinuses  and  of  the  meningeal  vessels,  in- 
cluding the  finer  branches ;  the  pia  mater  appears  vascular  and 
opaque  ;  \h&  gray  matter  of  the  convolutions  unduly  red  ;  the  convo- 
lutions may  be  compressed  and  the  ventricles  contracted,  with  the 
displacement  of  a  corresponding  amount  of  cerebro-spinal  fluid. 

Long-continued  or  repeated  congestions  lead  to  enlargement  and 
tortuosity  of  all  the  vessels,  a  moist  and  slimy  condition  (oedema) 
of  the  cerebral  substance,  and  an  increase  in  the  sub-arachnoid 
fluid. 

Symptoms.     "  Rush  of  blood  to  the  head  "  may  be  gradual  or 


DISEASES   OF   THE   CEREBRUM.         .  413 

sudden  m  its  onset,  the  symptoms  aggravated  by  the  recumbent  posi- 
tion. Headache,  with  paroxysmal  neuralgic  darts,  disorders  of  vision 
and  hearing,  buzzing  in  the  ears  and  sparks  before  the  eyes,  con- 
tracted pupils,  vertigo,  blunted  intellect,  inability  to  concentrate 
\h.QVs\\r\.dL,  irritable  temper,  ^.x\dL  curious  hallucinations.  The /ace  is 
red,  the  eyes  congested,  and  the  carotids  pulsating.  The  sleep  is  dis- 
turbed by  dreams  and  j'erkings  of  the  limbs.  If  the  attack  be  sudden 
(apoplectiform),  sudden  unconsciousness  with  muscular  relaxation 
occur. 

Cerebral  hyperaemia  in  children  often  presents  alarming  symptoms, 
such  as  great  restlessness,  insomnia,  night-terrors,  gnashing  of  the 
teeth  during  sleep,  vomiting,  contraction  of  pupils  followed  by  gejteral 
cottvulsions.  Any  or  all  of  these  symptoms  may  continue  more  or  less 
marked  from  an  hour  or  two  to  a  day,  the  child  enjoying  its  usual 
health,  after  a  sound  sleep,  save  a  feeling  of  fatigue. 

Prognosis.  Mild  cases  terminate  favorably  in  a  few  hours  to  a 
day  or  two,  but  show  a  strong  tendency  to  recur.  Severe  cases  (apo- 
plectiform) may  terminate  in  health,  but  usually  foretell  cerebral 
hemorrhage. 

The  passive  form  is  controlled  by  the  lesions  giving  rise  to  it. 

Treatment.  Active  form  :  Remove  the  cause  if  possible.  Elevate 
the  head  and  apply  cold,  either  cold  cloths  or  the  ice  cap ;  at  the  same 
time  warmth  to  the  feet.  Leeches  to  the  mastoid,  or  cups  to  the  neck, 
or  in  the  apoplectiform  variety  venesection,  to  diminish  the  intracranial 
blood  pressure  ;  compression  of  the  carotids,  or  ligatures  about  the 
thighs,  have  been  recommended. 

An  active  purgation  is  indicated,  either  by  oleutn  tiglii,  or  magnesii 
sulphas,  by  the  mouth.     The  following  enema  is  often  valuable  : 

R.     Magnesii  sulphatis, ,^ij  60.  Gm. 

Glycerini, f  Jj  30.  Cc. 

Aquee  bul., f^iv  120.  Cc.  M. 

SiG. — Administer  slowly  per  rectum,  with  little  force. 

In  mild  cases  the  application  of  an  ice  cap  to  the  head,  sinapis  to 
the  nucha,  and  potassii  brotnidwn,  gr.  xxx-xl  (2-2.6  Gm.),  repeated, 
and  the  enema  mentioned  above,  control  the  symptoms.  Extractum 
ergotce fuidum  is  strongly  recommended,  but  its  value  seems  to  be 
overestimated. 


414  .  PRACTICE    OF    MEDICINE. 

In  severe  cases,  with  forcible,  overacting  heart,  to  the  above  means 
must  be  added  tinctura  verairi  vitidis  or  iincdtra  aconili. 

Passive  form  :  Becomes  a  part  of  the  treatment  producing  the 
stasis. 


CEREBRAL   ANAEMIA. 

Definition,  An  abnormal  decrease  in  the  quantity  of  blood  in 
the  cerebral  vessels ;  general,  when  the  diminished  supply  includes 
all  the  vessels ; /rtr/zVi/,  when  the  diminished  supply  is  limited  in 
area ;  characterized  by  pallor,  headache,  vertigo,  some  loss  of  power, 
and,  rarely,  convulsions. 

Causes.  Partial  cerebral  anaemia  results  from  obstruction  of  a 
vessel,  from  embolism  or  thrombosis.  General  zt.xf^x?i\.  anasmia  re- 
sults from  hemorrhages,  wasting  diseases,  during  convalescence  from 
severe  attacks  of  fevers,  sudden  shock,  feeble  cardiac  action,  and 
general  anaemia. 

Pathological  Anatomy.  The  functional  activity  of  the  brain 
depends  upon  the  quantity  and  quality  of  the  blood  circulating  in 
the  cerebral  capillaries.  Any  decrease  in  the  normal  quantity  or 
impairment  in  the  quality  produces  the  symptoms  of  cerebral  anaemia. 
The  brain  is  pale  and  milky  in  color,  and  on  transverse  section  there 
are  no  bloody  points ;  the  ventricles  and  perivascular  lymph-spaces 
are  well  filled  with  fluid. 

In /^r//a/ anaemia  the  local  conditions  differ  somewhat  from  the 
above. 

Symptoms.  Getieral .-  Headache,  relieved  by  the  recumbent 
position  ;  vertigo,  aggravated  by  exertion  ;  general /a//<7r,  and  anae- 
mia with  attacks  oi  fainting ;  when  the  general  cerebral  anaemia  is 
sudden  and  decided,  convulsions  occur. 

Partial  ancemia  ;  sudden  loss  of  power  of  limited  muscular  area, 
gradually  returning  to  the  normal  condition. 

Prognosis.  Favorable  in  all  cases  save  those  the  result  of  severe 
and  repeated  hemorrhages. 

Treatment.  Regulated  nourishment,  with  stimulants.  A  certain 
number  of  hours  daily  in  the  recumbent  position  is  of  advantage. 
When  a  tendency  to  attacks  of  swooning  exists,  alcoholic  stimulants 
or  spiritus  ammonics  aromaticus  and  spiritus  cetheris  compositus  every 


DISEASES   OF  THE   CEREBRUM.  415 

few  hours  or  even  the  cautious  inhalation  of  atnyl  nitris  are  indi- 
cated.    To  improve  the  quantity  or  quality  of  the  blood — 

R.     Tiuct.  ferri  chlor. , TT^xv  I.     Cc. 

Acid,  phosph.  dil., n\,v  .3  Cc. 

Liq.  arsenici  chloridi, 'n\^iij  .2  Cc. 

Syr.  limonis,      f^ss  2.     Cc. 

Syr.  zingiberis,  .    .    .    .    q.  s.  ad  fgij  ad  8.     Cc.  M. 

SiG. — Every  six  hours,  well  diluted. 

Or— 

R.     Strychninse  sulph., gr.  j  .065  Gm. 

Quininse  sulph., gr.  xlviij  3.1       Gm. 

Acid,  hydrochlorici  dil.,      .    .    .f.^ij  8.         Cc. 

Tinct.  gentian,  comp. ,     ....  f.^iij  90.         Cc. 

Tinct.  card,  comp.,      .    q.  s.  ad  f^vj  ad   180.         Cc.  M. 

SiG. — Teaspoonful  in  water,  after  meals. 


CEREBRAL   HEMORRHAGE. 

Synonyms.     Apoplexy  ;  "  a  stroke." 

Definition.  The  sudden  rupture  of  a  cerebral  vessel  and  escape 
of  blood  into  the  cerebral  tissue,  causing  pressure  and  more  or  less 
destruction  of  the  brain  substance  ;  characterized  by  sudden  uncon- 
sciousness, irregular,  noisy  respiration,  and  complete  muscular  relaxa- 
tion. 

Causes.  Rare  under  forty  years  of  age.  The  principal  cause  is 
disease  of  the  vessels — the  development  of  miliary  aneurisms,  or  a 
chronic  endarteritis  with  an  associated  cardiac  hypertrophy  ;  heredi- 
tary tendency  ;  Bright's  disease  ;  syphilis  ;  alcoholic  and  dietary  ex- 
cesses,— chronic  alcoholism  is  probably  the  most  common  cause. 
Apoplexy  early  in  life  is  usually  syphilitic.  More  frequent  in  the 
spring  and  autumn. 

Pathological  Anatomy.  The  most  common  locations  of  cere- 
bral hemorrhage  are  the  regions  supplied  by  the  "  central  arteries," 
the  internal  capsule,  corpus  striatum,  and  thalamus  opticus ;  less 
common,  the  cerebellum;  next  in  frequency  the  pons  and  medulla 
oblongata,  and  rarely  on  the  convexity  of  the  brain,  termed  menin- 
geal hevaorrhdige. 

Intracerebral  hemorrhage  is  more  common  upon  the  right  than 
upon  the  left  side,  and  especially  affects  the  region  of  the  caudate 


410  PRACTICE    OF    MKDICINE. 

nucleus,  lenticular  nucleus,  internal  capsule,  and  optic  thalamus;  and 
particularly  the  outer  border  of  the  lenticular  body,  which  is  supplied 
by  the  striate  artery, — the  artery  of  cerebral  hemorrhage.  These 
lenticular  striate  arteries  are  branches  of  the  Sylvian  artery,  and  have 
no  anastomoses. 

When  the  hemorrhage  is  large,  the  blood  may  break  into  the  ven- 
tricles and  pass  by  the  iter  from  the  third  to  the  fourth  ventricle. 

A  recent  clot  is  dark  in  color,  and  in  consistency  a  soft,  grumous 
mass,  composed  of  coagulated  blood  and  brain  substance  in  varying 
proportions,  at  whose  centre  is  the  opening  into  the  ruptured  vessel. 
The  rA^/excites  inflammation  around  it,  resulting  in  its  being  encysted, 
by  the  development  of  new  connective  tissue  from  the  neuroglia,  and 
then  gradually  absorbed,  leaving  a  cicatrix  ;  or  the  brain  tissue  around 
the  clot  softens  and  degenerates — localized  softening. 

Symptoms.  The  attack  may  occur  suddenly  as  an  apoplectic 
shock  or  stroke,  or  slowly  with  prodromes  or  "  warnings." 

Prodromes:  Headache,  vertigo,  transient  deafness  or  blindness, 
sensation  of  numbness  of  the  extremities,  with  local  palsies,  together 
with  the  constant  dread  of  an  attack. 

The  attack  may  begin  with  vomiting,  followed  by  either  partial  or 
complete  insensibility,  or,  suddenly,  the  patient  becoming  at  once 
unconscious  and,  if  standing  at  the  time,  sinking  to  the  ground  com- 
pletely relaxed  or,  rarely,  with  spasmodic  or  convulsive  movements ; 
respiration  slow,  irregular,  and  noisy  ;  during  the  inspiration  the 
paralyzed  cheek  is  drawn  in,  and  puffed  out  in  expiration  ;  pulse 
slow  and  full ;  pupils  uninfluenced  by  light,  the/ar<r  flushed,  the  eyes 
congested,  and  the  carotids  ihxohhmg  ;  the  temperature  declines  below 
the  normal  a  degree  or  two,  but  rises  within  twenty-four  hours  to  loo** 
F.-ioi°  F.  In  fatal  cases  the  temperature  may  rapidly  rise  to  io6°  F. 
-io8°  F. 

The  muscular  system  is  profoundly  relaxed,  and  the  reflex  move- 
ments are  abolished.  The  head  and  eyes  deviate,  in  many  cases, 
toivard  the  affected  side  in  the  brain  or  from  the  paralyzed  side. 
Rarely  convulsions  occur. 

Ingravescent  apoplexy  begins  as  a  mild  stroke  with  a  rapid  return  to 
consciousness  and  power,  except,  perhaps,  of  speech.  Headache  is 
present  with  some  one  or  more  local  symptoms,  and  in  a  few  hours  to 
a  few  days  consciousness  gradually  becomes  impaired,  the  loss  of 
power  again  occurs,  the  coma  deepens,  the  patient  dying  comatose. 


DISEASES   OF   THE   CEREBRUM.  417 

If  the  unconsciousness  continues  longer  than  twenty-tour  hours, 
death  is  the  usual  termination,  preceded  by  paleface,  irregular  and 
rapid  pulse  and  respiration,  and  rise  of  temperature. 

Reaction  obtains  in  from  a  half  to  three  hours,  consciousness  re- 
turning, reflex  excitability  reviving,  associated  with  headache,  con- 
fusion of  mind,  and  more  or  less  paralysis  of  motion  and  sensibility 
of  one  side  of  the  body,  termed  hemiplegia. 

The  electro-excitability  of  the  paralyzed  parts  is  preserved. 

■Recovery  may  be  delayed  by  inflammatory  symptoms,  the  tem- 
perature rising  to  ioi°-io4°  F.,  with  tonic  contractions  {early  rigidity') 
of  the  paralyzed  muscles  and  severe  neuralgic  pains. 

Localization  of  the  lesion  of  a  cerebral  hemorrhage  is  of  great 
practical  importance. 

Capsular  hemorrhage  or  of  the  internal  capsule  at  the  anterior 
portion  around  the  genu  (knee),  where  the  motor  fibres  pass  and  con- 
verge coming  from  the  hemispheres,  is  a  frequent  site,  causing 
loss  of  consciousness  of  sudden  or  rapid  onset,  hemiplegia,  involving 
face,  arm,  and  leg,  with  motor  aphasia  if  the  hemiplegia  be  on  the 
right  side.  There  is  also  a  unilateral  loss  of  reflex  action,  conjugate 
deviation  of  the  eyes  from  the  paralyzed  side,  and  unilateral  defective 
movement  with  flaccidity  of  the  limbs. 

Cortical  hemorrhage ,  localized  unilateral  paralysis  of  the  face,  the 
arm,  or  the  leg,  with  local  convulsions  or  convulsions  that  have  a  local 
beginning,  or  profound  unconsciousness. 

Centrum  ovale  hemorrhages  resemble  the  cortical  with  the  local 
convulsions. 

Crus-cerebri  hemorrhage,  loss  of  consciousness  with  hemiplegia  in- 
volving the  lower  half  of  the  face  and  the  limbs,  with  paralysis  of  the 
third  nerve  on  the  opposite  side,  or  the  side  of  the  lesion.  The  uni- 
lateral third  nerve  symptoms  are  ptosis,  external  strabismus,  dilata- 
tion of  the  pupil,  and  loss  of  accommodation  for  near  objects.  The 
paralysis  is  termed  "  crossed  "  or  "  alternate  "  hemiplegia. 

Pons  hejnorrhage  causes  either  general  convulsions  or  irregular  con- 
vulsions in  the  legs,  bilateral  motor  paralysis,  bilateral  anaesthesia, 
either  contracted  or  dilated  pupils,  embarrassed  respiration,  repeated 
non-gastric  vomiting,  and  high  temperature.  If  the  hemorrhage  is 
large,  death  is  sudden  or  within  a  few  hours,  and  even  if  small,  the 
prognosis  is  unfavorable. 

Ventricular  hemorrhages  are  generally  of  the  ingravescent  variety, 
27 


418  PRACTICE    OF    MEDICINE. 

and  are  characterized  by  a  second  apoplectic  seizure  soon  after  the 
first,  with  extension  of  the  hemiplegic  symptoms  or  a  relaxation  of  the 
muscles  from  one  side  to  both  sides  of  the  body. 

Cerebellar  hevionhages  vary  so  greatly  in  the  symptoms  that  a 
positive  diagnosis  can  seldom  be  made. 

Meningeal  or  dural  hanorrhage  is  usually  due  to  a  trauma.  Two 
varieties:  I.  Infantile  tneningeal  hemorrhage,  occurring  during 
labor.  II.  Extra-dural  hemorrhage,  the  result  of  direct  injury  to 
the  head. 

The  infantile  variety  presents  symptoms  of  irritation  and  compres- 
sion of  the  cortex,  such  as  convulsions,  general  or  unilateral ;  rigidity, 
opisthotonos,  and  either  hemiplegia  or  diplegia. 

The  extra-dural  variety  is  almost  always  the  result  of  fracture  or 
trauma  of  the  skull,  resulting  in  an  extravasation  of  blood  between 
the  dura  and  the  skull  from  the  middle  meningeal  artery  ;  the  hem- 
orrhage may  be  on  one  or  both  sides.  The  symptoms  may  develop 
at  once  or  after  some  days,  and  are  those  of  pressure;  hemiplegia, 
partial  or  complete;  convulsions,  impaired  or  absent  reflexes,  dila- 
tation with  loss  of  reaction  of  pupil  of  opposite  side  ;  stupor,  gradually 
deepening  into  coma  and  death. 

Sequelae.  Paralysis  of  the  muscles  of  the  face,  tongue,  body, 
and  extremities  of  one  side,  opposite  to  the  location  of  the  hemor- 
rhage, termed  unilateral  paralysis  or  right  or  left  hemiplegia. 

Paralysis  of  both  sides  of  the  body,  due  to  simultaneous  hemor- 
rhage on  both  sides,  termed  bilateral  hemiplegia,  or  diplegia. 

Paralysis  of  one  side  of  the  face  and  of  the  extremities  of  the  oppo- 
site side,  due  to  hemorrhage  into  the  pons  Varolii,  termed  alternating 
or  crossed  paralysis. 

Occasionally  tonic  contractions  occur  in  muscles  long  paralyzed, 
termed  late  rigidity,  and  is  evidence  of  a  secondary  degeneration  of 
the  nerve  fibres. 

Choreic  movements  in  paralyzed  muscles  are  termed  post-hemi- 
plegic  chorea,  due,  according  to  Charcot,  to  changes  in  the  motor 
centres. 

The  mental  powers  are  always  more  or  less  permanently  impaired, 
the  patient  irritable  and  emotional,  and  the  same  holds  good  con- 
cerning the  memory. 

Diagnosis.  The  diagnosis  of  the  apoplectic  seizure  is  often  one 
of  the  most  difficult  questions  in  medicine,  and  yet  of  the  greatest 


DISEASES   OF  THE   CEREBRUM.  419 

importance,  as  the  treatment  depends  upon  its  correctness.  The 
diagnosis  of  the  sequelse  is  comparatively  easy. 

Insensibility  from  drink  differs  from  apoplexy  in  the  following 
points:  insensibility  is  not  so  complete,  no  drawing  in  and  puffing 
out  of  one  cheek  with  respiration,  the  pulse  frequent  instead  of  slow, 
the  pupils  influenced  by  light;  upon  raising  both  legs,  no  difference 
is  apparent  on  allowing  them  to  drop  ;  the  eyes  and  head  are  not 
turned  to  one  side,  and,  lastly,  the  condition  is  ameliorated  on  the 
inhalation  of  ammonia.  Dr.  von  Wedekind's  test  for  temulence  is 
generally  satisfactory :  "  By  simply  pressing  on  the  supraorbital 
notches  with  a  steadily  increasing  force  you  may,  with  certainty  of 
success,  bring  an  unconscious  alcoholic  to  his  senses,  and  thus  differ- 
entiate between  alcoholic  and  other  comas." 

Opium  poisoning  differs  from  apoplexy  by  the  gradual  approach  of 
the  coma,  the  contracted  pupil  and  slow  pulse,  and  quiet,  slow  res- 
piration, and  that  the  patient  can  be  momentarily  aroused,  and  also 
by  the  absence  of  the  heavy  stertor  of  apoplexy. 

Urcemia  causes  a  coma  that  closely  resembles  apoplexy.  A  history 
of  Bright's  disease  at  once  clears  up  the  case  ;  again,  ursemic  coma  is 
generally  preceded  by  convulsions ;  a  rapid  rise  of  temperature,  as 
shown  by  the  thermometer,  often  104°  F.  to  106°  F.,  while  to  the  hand 
the  surface  appears  but  little,  if  at  all,  above  the  normal ;  the  pulse 
is  usually  weak  with  irregular  force,  the  respirations  averaging 
twenty-five  to  thirty  per  minute,  the  face  having  a  glossy  appearance. 

Cerebral  embolism  cannot  always  be  differentiated  from  apoplexy. 
We  may  suspect  cerebral  plugging  if  the  patient  be  young ;  if  he  be 
laboring  under  acute  or  chronic  cardiac  valvular  trouble ;  if,  within 
brief  periods,  several  incomplete  attacks  have  occurred  before  a 
complete  comatose  condition  obtains ;  or,  if  hemiplegia  results  with 
passing  or  slight  unconsciousness  ;  or,  if  the  phenomena  are  sooner 
or  later  followed  by  cerebral  softening,  as  embolism  and  thrombosis 
are  the  most  common  causes  of  softening. 

Syncope  or  a  fainting-fit  is  of  sudden  onset,  but,  being  due  to  a 
failure  of  the  circulation,  the  pulse  is  feeble,  the  face  pale,  the  respi- 
rations quiet,  and  the  duration  of  unconsciousness  short,  all  the  very 
opposite  of  an  apoplectic  attack. 

Prognosis.  If  the  patient  survive  the  immediate  effects  of  a 
cerebral  hemorrhage,  he  is  always  in  danger  of  a  new  attack, 
since  the  causes  of  The  original  attack  still  remain.     Another  attack 


420  I'RACTICE    OF    MEDICINE. 

or  two  is  the  usual  course,  a  fatal  termination  ultimately  occurring. 
If  the  attack  be  due  to  or  associated  with  Bright's  disease,  recovery  is 
rare. 

The  heiniple^i^ia  is  uncertain  ;  a  partial  recovery  may  occur  within 
a  few  months  or  it  may  continue  for  years. 

Treatment.  If  there  are  prodromal  indications,  the  most  prompt 
means  of  reducing  the  intracranial  blood  pressure  is  by  venesection, 
followed  by  a  brisk  purgative,  which  may  be  aided  by  an  immediate 
enema : 

R.     Magnesii  sulph., 5ij  60.  Gm. 

Glycerin!, f.jj  30.  Cc. 

Aquce  bulla", f.^'U  9°-  Cc. 

SiG. — Administer  by  bowel  slowly  without  force. 

If  the  patient  be  weak,  however,  leeches  to  the  mastoid,  and  potassii 
broinidum,  gr.  xl-lx  (2.6-4  Gm.),  or  extractiim  ergotce  fluidum,  fjss-j 
(2-4  Cc),  may  be  substituted. 

For  the  attack,  loosen  clothing,  elevate  the  head,  remove  constric- 
tions, place  in  a  cool  room,  have  perfect  quiet,  placing  the  patient 
sufficiently  on  his  side,  with  the  face  somewhat  downward,  for  the 
tongue  and  palate  and  secretions  to  fall  forward  instead  of  backward 
into  the  pharynx,  and  at  once  venesection,  cold  to  head,  a  mustard 
foot  bath,  and  oletim  tiglii,  Tt^j-iij  (0.06-0.2  Cc),  \s\\\s. glycerimwi ,  tt\^  xv 
(i  Cc),  placed  on  back  of  tongue  ;  if  the  pulse  be  full  and  strong, 
when  consciousness  is  regained,  either  iinctttra  veratri  viridis  or 
tinctura  aconiti  is  indicated. 

If  during  the  attack  the/^^^  be  pallid  and  the  pulse  irregular,  and 
the  patient  is  prostrated  by  the  shock,  stimulants  and  digitalis  are  in- 
dicated, with,  perhaps,  leeches  to  the  mastoid  and  an  enema  of  tere- 
binthifia. 

For  the  secondary  fever,  either  tinctura  aconiti  or  tinctura  veratri 
viridis ;  for  the  headache  and  delirium,  camphorce  bro?nidum. 

For  promoting  the  absorption  of  the  clot,  keep  the  secretions  active, 
a  good  diet  and  a  course  oi potassii  iodidum  or  hydrargyri  chloridum 
corrosivum,  alternated  with — 

li .      Liq.  potassii  arsenit., TT\^  v  .3  Co. 

Syr.  calcii  lacto-phosph.,      .    .    .  fjij  8.    Cc. 

Three  times  a  day. 

After  two  or  three  months  a  ^^d^i  galvanic  current  appWed  directly 


DISEASES   OF   THE   CEREBRUM.  421 

to  the  brain,  by  placing  an  electrode  on  each  mastoid  process,  pro- 
motes absorption. 

Yor  the  paralyzed  muscles,  \he  faradic  current,  applied  by  placing 
one  electrode  over  or  near  the  nerve  innervating  the  muscle  and  the 
other  over  its  belly,  acts  as  a  tonic,  preventing  wasting;  it  is  assisted 
by  hypodermic  injections  into  the  paralyzed  muscles  of  strychnincB 
sulphas,  gr.  g'j  (o.ooi  Gm.),  four  times  a  week. 


CEREBRAL  THROMBOSIS  AND  EMBOLISM. 

Synonyms.  Partial  cerebral  anaemia ;  occlusion  of  cerebral 
vessels ;  cerebral  apoplexy  (?). 

Definition.  The  occlusion  of  a  cerebral  vessel,  from  the  forma- 
tion of  a  thrombus  or  the  presence  of  an  embolus,  thus  causing  ancemia 
of  some  portion  of  the  brain  ;  characterized  by  the  gradual — when  the 
result  of  thrombosis,  and  the  sudden,  when  due  to  embolism — devel- 
opment of  headache,  vertigo,  disorders  of  intelligence,  with  more  or 
less  complete  insensibility  and  paralysis. 

Causes.  Thrombosis,  or  the  formation  of  a  clot  in  the  vessel, — 
an  ante-mortem  coagulation, — is  almost  always  the  result  of  chronic 
endarteritis,  as  seen  in  the  aged,  together  with  a  slowing  and  weaken- 
ing of  the  blood  current.  Chronic  alcoholism  and  syphilis  are  the 
usual  causes  when  occurring  in  young  adults. 

Emboli,  in  the  great  majority  of  instances,  result  from  an  endocar- 
ditis— cardiac  emboli  ;  small  particles  of  the  exudation  being  carried 
into  the  circulation  and  deposited  in  the  brain.  Emboli  may  also  be 
derived  from  an  aortic  aneurism  or  syphiloma  of  the  great  vessels. 

Pathological  Anatomy.  The  cerebral  arteries  may  be  ob- 
structed by  emboli  or  thrombi :  the  cerebral  veins  and  sinuses  by 
thrombi  only.  The  changes  in  the  cerebral  tissue  are  those  of  anaemia 
of  the  part  or  parts  supplied  by  the  occluded  vessels.  The  subsequent 
changes  depend  upon  the  anatomy  of  the  vessels.  If  the  obstructed 
artery  has  anastomoses,  the  collateral  circulation  is  soon  established 
and  the  brain  tissue  assumes  its  normal  condition.  If,  on  the  other 
hand,  the  occluded  vessel  be  one  of  "  Cohnheim's  terminal  arteries," 
— arteries  without  anastomoses,  such  as  the  lenticular-optic  and  the 
lenticular-striate  set  of  arteries,  branches  of  the  Sylvian  artery, — 
the  blood  in  the-whole  extent  of  the  occluded  vessels  coagulates, 
thus  preventing  the  backward  flow  of  blood  from  the  surrounding 


422  PRACTICE    OF    MEDICINE. 

capillaries  and  so  obstructing  collateral  circulation,  whence  the 
anaemic  tissue  dies  or  undergoes  necrobiosis,  followed  by  yellowish- 
white  softening;  or,  if  the  vessel  beyond  the  seat  of  the  occlusion 
remains  pervious,  blood  flows  back  through  the  capillaries  from  the 
nearest  artery  or  vein,  the  parts  that  a  short  time  before  were  blood- 
less, now  become  deeply  engorged,  the  succeeding  changes  in  the 
vessels  permitting  diapcdesis  of  the  red  blood  globules.  The  tissues 
which  are  undergoing  disintegration  are  colored  by  the  red  globules, 
causing  the  appearance  entitled  "red  softening,"  which  after  some 
weeks  becomes  "yellow  softening,"  finally  changing  to  "white 
softening,"  when  there  is  a  milky,  or  rather  creamy  fluid  mixed  with 
masses  or  particles  of  broken-down  nerve  elements. 

The  vessel  most  commonly  occluded  is  the  left  7niddle  cerebral 
artery,  which  sends  branches  to  the  second  and  third  frontal  convo- 
lutions, the  anterior  and  superior  portions  of  the  three  temporal 
convolutions,  the  island  of  Reil,  the  parietal  convolutions,  part  of  the 
external  and  all  of  the  internal  capsule,  the  lenticular  nucleus,  and 
most  of  the  corpus  striatum, — the  motor  centres. 

Symptoms.  Two  distinct  modes  of  onset :  Gradual,  when  the 
result  of  thrombosis  ;  sudden  or  apoplectic,  when  due  to  embolism. 

Cerebral  thrombosis  :  Most  common  in  the  aged.  Persistent  A^(Z^- 
ache  and  vertigo,  at  one  time  severe  and  at  another  mild.  Next, 
alterations  in  the  patient's  character;  irritable,  7norose,  and  despondent, 
with  periods  oi  absent-mindedness,  disorders  of  vision,  and  impairfnent 
of  vieviory,  speech  becoming  hesitating  and  mumbling.  Impaired 
locomotion,  the  result  of  the  vertigo,  and  of  muscu/ar  -weakness  and 
trembling,  followed  sooner  or  later  by  hemiplegia,  which  may  be 
preceded  by  sudden  insensibility  or  occur  gradually,  the  symptoms 
slowly  proceeding  to  dementia  and  death  from  exhaustion  ;  or, 
rarely,  the  symptoms  are  not  so  grave,  and  partial  or  complete  re- 
covery occurs  after  the  hemiplegia,  from  establishment  of  the  "  col- 
lateral circulation." 

Cerebral  embolism.  The  symptoms  are  sudden,  but  either  mild  or 
grave  in  character. 

Alild  variety  ;  sudden  and  severe  vertigo,  confttsion  of  mind,  mus- 
cular iwitchings,  usually  one-sided,  and  vomiting,  followed  by  hemi- 
plegia, most  frequently  of  the  right  side,  the  intellect  clear  but  hesi- 
tating. After  some  weeks  or  months  the  paralysis  usually  disappears 
and  recovery  is  complete. 


DISEASES   OF  THE  CEREBRUM.  423 

Grave  or  apoplectic  variety.  Sudden  headache,  vertigo,  flushing 
ox  pallor  of  the  face,  or  the  patient  may  utter  a  sharp  cry,  fall  to  the 
ground  with  sudden  unconsciousness  and  complete  mtiscular  relaxa- 
tion, followed  by  death  or  a  gradual  return  of  consciousness  with 
heiniplegia,  which  is  generally  right-sided,  with  aphasia,  remaining  for 
several  weeks  or  months,  or  is  persistent,  the  mind reniaitiing  normal 
or  enfeebled  z.x\^  the  emotional  nature  highly  excitable  and  the  reason 
and  judgment  clouded,  continuing  thus  for  years,  or  gradually  devel- 
oping into  dementia,  exhaustion,  and  death. 

The  following  are  some  of  the  symptoms  of  "  localization  "  if  par- 
ticular vessels  are  blocked : 

Vertebral  artery,  the  left  most  frequently,  results  in  acute  bulbar 
paralysis  from  involvement  of  the  nuclei  in  the  medulla,  associated 
or  not  with  hemiplegia. 

Basilar  artery  causes  diplegia  with  bulbar  symptoms.  There  is 
rapid  rise  of  temperature.  Death  follows  within  a  day  or  two,  or  sud- 
denly, if  the  respiratory  centres  are  involved. 

Middle  cerebral  artery  or  one  of  its  branches  is  the  most  frequent 
seat  of  embolic  or  thrombotic  occlusions.  The  symptoms  depend 
upon  the  exact  branch  involved  ;  if  plugged  before  the  central  arteries 
are  given  off,  the  internal  capsule  is  deprived  of  its  blood  supply 
and  permanent  hemiplegia  may  follow ;  if  the  blocking  is  in  the 
central  branches,  the  hemiplegia  involves  the  arm  and  face,  and  if 
the  left  side,  aphasia  occurs.  The  individual  branches  passing  to  the 
third  frontal  (aphasia),  the  ascending  parietal  (hemiplegia,  particularly 
hand),  supra-marginal  and  angular  gyri  (word  blindness),  and  the 
temporal  gyri  (word  deafness),  may  be  plugged. 

Duration.  Thrombosis,  essentially  an  affection  of  the  elderly,  and 
has  a  chronic  course.  Months  and  years  may  be  occupied  with  the 
various  symptoms  until  the  phenomena  of  secondary  dementia  de- 
velop. 

Embolism  is  of  sudden  onset,  and  may  be  followed  by  a  rapid 
recovery. 

Diagnosis. — Thrombosis  is  associated  with  changes  in  the  ves- 
sels, the  arcus  senilis,  and  other  evidences  of  senile  degeneration. 

Embolism  may  be  mistaken  for  cerebral  apoplexy,  and,  while  a 
positive  differentiation  cannot  always  be  made,  an  important.point  to 
be  considered  is  the  presence  of  cardiac  murmurs. 

Prognosis.  Thrombosis  is  a  permanent  and  progressive  condition 
in  the  majority  of  instances.     Recovery  is  a  rare  termination. 


424  PRACTICE    OF    MEDICINE. 

Embolism  may  be  followed  by  a  perfect  recovery.  Usually,  how- 
ever, some  evidences  of  the  plugging  remain  permanently.  Death 
may  be  the  result  within  a  day  or  two,  from  the  plugging  of  a  large 
vessel,  the  patient  never  emerging  from  the  coma.  In  other casesthe 
patient  arouses  from  the  coma,  the  hemiplegia  with  aphasia  persisting, 
and  the  case  pursues  the  usual  course  of  localized  cerebral  softening. 

Treatment.  The  indication  in  the  early  stage  of  embolism  and 
thrombosis  is  the  re-establishment  of  the  circulation  within  the  area 
deprived  of  its  blood  supply,  in  order  to  prevent  the  changes  incident 
to  defective  nutrition  ;  this  is  accomplished  by  measures  to  strengthen 
the  heart's  action,  tonics,  perfect  rest  for  some  time  after  the  attack, 
a  plain  but  nutritious  diet,  and  attention  to  the  various  secretions. 

Prof.  Bartholow  "  has  had  remarkable  results  from  the  following 
plan  of  treatment  in  thrombosis  "  :  Arnmonii carbonas,  gr.  x  (06  Gm.), 
with  ammonii  iodidum,  gr.  v  (0.3  Gm.),  three  times  a  day,  continued 
for  several  months,  "  the  object  being  dual — to  increase  the  action  of 
the  heart  and  arteries,  and  to  effect  a  solution  of  thrombi  forming  by 
maintaining  the  alkalinity  of  the  blood." 

In  the  aged,  presenting  indications  of  degeneration,  much  benefit 
results  from  the  use  of — 

K .     Liiiuor.  potassii  arsenitis,     .    .    .    Tt\^iij  .2  Cc. 

Syr.  calcii  lacto-phosphat. ,  .    .    .  f  ;:5  ij  8.     Cc.  M. 

SiG. — After  meals,  well  diluted. 

It  may  be  combined  with  oleum  morrhuce  with  decided  advantage. 
For  embolism,  the  immediate  and  persistent  use  of  the  following 
may  dissolve  the  plug : 

R.     Ammonii  carbonat gr.  v  .3  Gm. 

Liquor,  ammonii  acetatis,     .    .    .  f ^j  4.     Cc.  M. 

SiG. — Three  or  four  times  daily,  well  diluted. 

"  In  a  month  or  two  a  very  light  galvanic  current  (from  two  cups) 
may  be  passed  through  the  brain  in  both  directions  "  (Bartholow). 


CEREBRAL  ABSCESS. 

Synonyms.     Acute  encephalitis;  suppurative  encephalitis. 

Definition.  An  acute  suppurative  inflammation  of  the  brain 
structure,  either  localized  or  diffused,  primary  or  secondary  ;  charac- 
terized by  impairment  of  intellect,  sensation,  and  motion. 


DISEASES   OF  THE   CEREBRUM.  425 

Causes.  Primary  ceredra/ abscess  is  exceedingly  rare.  Pyaemia; 
glanders  ;  embolus  from  ulcerative  endocarditis. 

Secondary  cerebral  abscesses  result  from  injuries  to  the  cerebral 
tissues,  following  apoplexy,  embolism,  thrombosis,  and  injuries  to  ihe 
cranial  bones.  Chronic  suppurative  otitis ;  chronic  suppuration  in 
some  other  portion  of  the  body. 

Pathological  Anatomy.  Abscesses  of  the  brain  may  be  single 
or  multiple,  varying  in  size  from  an  almond  to  an  egg. 

It  occupies  a  limited  and  well-defined  region  of  the  cerebral  tissue, 
such  as  either  the  corpora  striata,  optic  thalami,  gray  matter  of  the 
cortex,  the  cerebellum,  or  the  white  matter  of  the  hemispheres. 

Cerebral  abscesses  are  usually  due  to  micro-organisms.  Abscesses 
are  more  frequent  in  the  right  hemisphere  than  the  left.  When  the 
result  of  pyaemia  or  infection  from  distant  organs,  such  as  the  lungs, 
they  are  generally  multiple.  When  secondary  to  disease  of  the  ear, 
frontal  sinuses,  nasopharynx,  or  trauma,  they  are  generally  single. 

An  abscess  having  developed,  steadily  increases  in  size,  encroach- 
ing upon  the  surrounding  brain,  and  usually  the  brain  tissue  forms  a 
defensive  wall  about  the  abscess — a  capsule  or  pyogenic  membrane. 
The  incapsulated  abscess  continues  to  develop,  finally  bursting,  in- 
filtrates the  surrounding  tissue  with  consequent  pressure,  or  discharges 
into  the  meshes  of  the  pia  arachnoid,  on  the  cortex  or  into  the  lateral 
ventricles.  Rarely,  an  incapsulated  abscess  may  become  perma- 
nently encysted.  The  pus  of  cerebral  abscess  is  greenish  or  greenish- 
yellow  in  color  and  foetid  (Dercum). 

Symptoms.  A  concise  description  of  the  symptoms  of  abscess 
of  the  brain  is  very  difficult,  on  account  of  the  wide  variations  depend- 
ent on  its  location,  and  also  the  difficulty  of  isolating  it  from  the  affec- 
tions to  which  it  is  secondary. 

The  onset  varies  according  to  the  cause,  although  all  cases  are 
associated  with  headache,  irritative  fever,  vomiting,  persistent  and 
spreading  paralysis,  convulsions,  optic  neuritis,  mental  apathy,  de- 
lirium, and  coma. 

If  following  apoplexy,  thrombosis,  or  emboli,  there  occurs  fever 
and  delirium,  the  paralysis  remaining  and  spreading  with  spasmodic 
contractions  of  the  affected  muscles. 

If  secondary  to  a  chronic  ear  disease,  there  is  following  sudden  stop- 
page of  the  ear  discharge  ;  severe  pain  in  ear  and  side  of  head,  accom- 
panied with  chill,  fever,  vomiting,  followed  in  a  few  days  by  the  disap- 


420  PRACTICE   OF    MEDICINE. 

pearance  of  febrile  symptoms  and  the  development  of  a  condition  of 
stupor,  with  cerebral  symptoms,  depending  upon  the  location  of  the 
abscess. 

Occasionally  cases  run  a  chronic  course,  the  onset  rather  insidious; 
dull,  persistent  headache  ;  changed  disposition,  peevish,  irritable,  un- 
reliable, with  decline  of  moral  sensibility  ;  easily  fatigued  by  mental 
work ;  inability  to  stand  exertion  ;  memory  impaired  ;  vertigo  ;  dys- 
pepsia, soon  followed  by  slight  palsies,  which  progressively  increase, 
becoming  general,  with  involuntary  discharges,  death  following  from 
exhaustion. 

Of  the  focal  symptoms,  hemiplegia,  of  incomplete  character,  occurs 
in  about  one-half  of  all  cases  of  abscess  of  the  brain.  A  very  con- 
stant symptom  of  diagnostic  value,  when  hemiplegia  is  very  marked, 
is  exaggerated  knee-jerk  with  pronounced  ankle  clonus. 

Diagnosis.  A  positive  diagnosis  is  only  possible  by  a  close  study 
of  the  causes  and  the  clinical  history,  as  the  symptoms  at  times  indi- 
cate meningitis  and  again  cerebral  tumor. 

Purulent  meningitis  may  follow  trauma  to  the  brain  or  chronic  ear 
disease,  making  the  diagnosis  impossible.  The  chief  points  of  dis- 
tinction are  :  The  subacute  or  chronic  course  of  abscess,  slight  involve- 
ment of  cranial  nerves,  hemiplegia,  and  the  presence  of  an  active, 
persistent,  unilateral  ankle  clonus  and  exaggerated  knee-jerk  on 
paralyzed  side. 

Prognosis.  The  usual  termination  is  in  death.  The  course  de- 
pends upon  the  character  and  extent  of  the  injury,  varying  from  a 
few  days  to  several  months. 

Treatment.  Surgical  treatment  has  been  attended  with  marked 
success  in  some  cases  of  abscess  of  the  brain,  the  withdrawal  of  the 
pus  being  followed  by  recovery.  For  traumatic  abscess  the  operation 
of  trephining  is  indicated.  Symptomatic  treatment  for  relief  of  the 
various  symptoms  as  they  arise. 


INTRA-CRANIAL  TUMOR. 

Synonym.     Cerebral  tumors. 

Definition.  Tumor  of  the  brain  is  either  a  growth  in  the  cere- 
bral tissue,  on  the  meninges,  or  in  the  vessels ;  characterized  by 
symptoms  of  pressure  upon  the  brain  structure. 

Causes.  Injuries  to  the  head  ;  syphilis;  changes  in  the  vessels  ; 
tubercle  and  cancer;  heredity. 


DISEASES   OF  THE   CEREBRUM.  427 

Pathological  Anatomy.  The  size  of  tumors  varies,  and  they 
may  become  as  large  as  an  orange  before  they  will  give  rise  to 
symptoms. 

Tumors  of  the  brain  are  of  various  kinds — to  wit :  vascular  tumors 
— aneurisms  ;  parasitic  tumors — cysticercus  ;  diathetic  tumors — tu- 
bercle or  syphilis  ;  accidental  tumors — glioma. 

Whatever  the  character  of  the  growth,  it  produces  irritation  of  the 
surrounding  parts,  and  by  pressure,  destruction  of  the  tissues,  or 
interferes  with  the  arterial  or  venous  supply. 

Symptoms.  Those  common  to  tumors  in  general  are  :  Headache, 
persistent  and  increasing  in  intensity ;  defects  of  vision,  even  blind- 
ness, due  to  an  optic  neuritis,  a  very  constant  symptom  ;  defects  of 
hearing,  taste,  and  oi  speech,  the  result  of  paresis  of  the  vocal  cords ; 
z/^r/i!^«7,  associated  with  nausea  and  vomiting ;  convulsions,  e.T^We'pii- 
form  in  character,  usually  limited  to  one  side  of  the  body,  occurring 
at  regular  intervals,  or  confined  to  the  eyeballs  (nystagmus)  or  ore 
limb,  with  no  loss  of  cojtsciousness; palsies,  beginning  first  as  strabismus, 
ptosis,  and  dilatation  of  the  pupil,  of  the  facial  muscles,  paraplegia 
and  general  hemiplegia ;  defects  of  sensibility,  such  as  sensations  of 
numbness  and  coldness  in  the  limbs  and  body.  Occasionally  dis- 
turbances of  equilibrium,  manifested  by  a  tendency  to  go  backward 
or  turn  to  the  right  or  left;  intellectual  faculties  well  preserved  until 
late  in  the  affection,  when  the  memory  becomes  impaired  or  lost  for 
certain  articles,  and  finally  a  gradually  advancing  dementia. 

Diagnosis.  Rarely  can  a  positive  diagnosis  be  made.  The  fol- 
lowing points  will  aid :  Long-continued  persistent  headache,  without 
appreciable  cause ;  epileptiform  convulsions,  unilateral,  without  loss 
of  consciousness;  difficulty  of  vision,  hearing,  and  speech,  associated 
with  nausea  and  vomiting,  and  local  and  general  palsies. 

The  location  of  the  tumor  may  be  determined  by  the  more  or  less 
pronounced  character  of  certain  symptoms. 

The  diagnosis  of  the  character  of  the  growth  can  only  be  deter- 
mined by  a  close  study  of  the  history. 

According  to  Hei'ter,  the  indications  that  suggest  that  the  tumor 
is  a  syphilitic  growth  are  as  follows :  Syphilitic  history ;  symptoms 
of  irritative  disease  of  cortex  rather  than  destructive  evidences  of 
rapid  growth  at  the  onset,  followed  -by  a  period  of  slow  progress  or 
stationary  symptoms;,  gradual  improvement  under  anti-syphilitic 
treatment;  development  between  twenty  and  forty-five  years  of  age. 


428  PRACTICE    OF    MEDICINE. 

Indications  suggesting  tubercular  growth  are  :  Family  history  of  or 
tuberculosis  in  some  other  organ  of  the  patient ;  rapid  development 
of  symptoms  ;  indications  of  the  growth  in  the  cerebellum  or  in  the 
pons;  early  appearance  of  the  symptoms,  especially  before  the  tenth 
year,  and  history  of  injury  to  head. 

Indications  suggesting  sarcovia  or  cancer  are :  The  presence  of  a 
sarcoma  elsewhere  and  rapidly  failing  health,  with  cerebral  tumor 
symptoms  in  patient  over  fifty  years. 

Indications  suggesting  glioma  :  Sudden  loss  of  consciousness  with 
exacerbation  of  all  symptoms  in  the  clinical  history  of  cerebral  tumor ; 
cortex  irritative  symptoms  as  in  syphiloma,  developing  under  fifty 
years  of  age,  and  the  absence  of  all  evidences  of  tubercle,  syphilis, 
sarcoma,  and  cancer. 

The/ocal  symptoms  of  intracranial  tumors  are  so  important  in  diag- 
nosis that  the  following  summary  is  given  of  symptoms  caused  by 
brain  tumors : 

Prefrontal  region.  Mental  impairment ;  pressure  in  central  region, 
causing  aphasia,  Jacksonian  epilepsy,  and  disturbances  of  smell. 

Central  region.  Motor  aphasia,  monoplegia,  partial  anaesthesia, 
Jacksonian  epilepsy. 

Posterior  parietal  region.  Word-blindness,  homonymous  hemi- 
anopsia, disturbed  muscular  sense. 

Corpus  callosum.     Progressive  hemiplegia. 

Crus  cerebri.     Crossed  paralyses  of  oculo-motor  nerve  and  limbs. 

Corpora  quadrigemina.  Oculo-motor  paralyses,  reeling  gait,  possi- 
bly blindness  and  deafness. 

Pons  and  medulla.  Crossed  paralysis  of  face  and  limbs,  or  tongue 
and  limbs.     Other  lesions  in  cranial  nerves. 

Cerebellum.  Marked  cerebellar  ataxia,  vomiting,  convulsions,  coma. 

Base,  anterior  fossa.  Mental  enfeeblement,  and  disturbances  of 
smell  and  vision,  exophthalmos. 

Base,  jniddle  fossa.  Impairment  of  vision  ;  hemiplegia ;  oculo- 
motor disturbances. 

Base,  posterior  fossa.  Trigeminal  neuralgia  ;  neuroparalytic  oph- 
thalmia ;  paralysis  of  the  face  and  tongue ;  impaired  hearing ;  crossed 
paralyses. 

Diagnosis  between  cerebral  tumor  and  abscess.  Both  may  have 
any  or  all  of  the  following  symptoms  :  Headache,  vomiting,  double 
optic  neuritis,  and  mental  failure.     Tumor  has,  in  addition,  marked 


DISEASES   OF   THE   CEREBRUM,  429 

/oca/  symptoms,  monoplegia,  hemiplegia,  paralysis  of  cranial  nerves, 
and  marked  optic  neuritis  ;  the  absence  of  these  favor  abscess,  or  if 
hemiplegia,  the  ankle  clonus  and  knee-jerk  is  exaggerated.  Fever 
and  rigors  point  to  abscess.  The  causes  of  abscess  are  very  clear, 
those  of  tumor  often  uncertain. 

Prognosis.  Unless  of  syphilitic  origin,  unfavorable;  but  it  is  to 
be  borne  in  mind  that  all  syphiUtic  tumors  of  the  brain  do  not  have 
a  favorable  termination. 

Treatment.  Unsatisfactory.  Mostly  symptomatic.  As  benefit 
occasionally  follows  the  use  oi potassii  iodidum,  gr.  xx  (1.3  Gm.),  three 
times  a  day,  or  ext.  ergoi(£  fid.,  f^ss-j  (2-4  Cc),  three  times  a  day, 
continued  until  their  physiological  effects  are  produced,  these  reme- 
dies should  be  used  in  all  cases,  discontinuing  them  if  no  benefit  fol- 
low. 

The  surgical  treatment  of  tumors  of  the  brain  was  given  a  great 
impetus  from  the  report  of  the  case  operated  upon  in  the  practice  of 
Hughes-Bennet.     The  surgical  treatment  is  promising  for  the  future. 


APHASIA. 

Definition.  Aphasia  is  a  symptom  and  not  a  disease.  A  loss  of 
memory  for  words.  The  loss,  partial  or  complete,  of  the  power  of 
expression  or  comprehension  of  language. 

Amnesic  aphasia,  or  loss  of  the  memory  of  words  by  which  ideas 
are  expressed. 

Ataxic  aphasia,  the  inability  to  combine  the  different  parts  of  the 
vocal  apparatus  for  vocal  expression,  although  the  memory  of  words 
still  remains,  so  that  the  afflicted  person  can  write  his  ideas  intelli- 
gently. 

Agraphia,  the  inability  to  recognize  and  make  signs  by  which 
ideas  are  communicated  in  written  language. 

Amnesic  agraphia,  the  inability  to  combine  the  muscular  apparatus 
— "writers'  cramp." 

Paraphasia,  the  mental  state  in  which  the  wrong  words  are  used 
to  express  the  idea. 

Paragraphia,  the  state  in  which  wrong  or  meaningless  written  signs 
are  used  to  express  the  idea. 

Pathological  Anatomy.  The  distinction  between  aphasia  and 
aphonia  must  be  clearly  determined. 


430  PRACTICE    OF    MKDICINE. 

Aphasia  is  not  the  result  of  any  one  specific  lesion,  but  occurs 
during  the  course  of  several — to  wit :  Occlusion  of  certain  cerebral 
vessels;  cerebral  hemorrhage;  cerebral  abscess  or  softening  ;  men- 
ingitis; tumors;  mental  or  moral  causes  ;  hysteria (?). 

It  is  now  almost  definitely  determined  that  lesions  of  the  left 
middle  cerebral  artery,  island  of  Reil,  third  frontal  convolution,  and 
parts  of  the  corpus  striatum  are  associated  in  the  production  of 
aphasia.  The  lesions  are  usually  upon  the  left  side  of  the  brain, 
the  aphasia  being  often  associated  with  right  hemiplegia. 

Symptoms.  The  degree  to  which  articulate  language  is  impaired 
varies  from  the  loss  of  a  few  words  to  complete  inability  to  communi- 
cate ideas.  The  intellect  does  not  suffer  in  proportion  to  the  loss  of 
words;  for,  showing  the  individual  an  article,  while  he  may  miscall 
it,  if  you  call  it  by  name  he  will  recognize  it.  This  inability  to  convey 
thoughts  is  a  source  of  great  mental  suffering,  in  some  leading  to  a 
suicidal  tendency. 

A  strange  clinical  fact  is  the  strong  tendency  to  profanity  shown 
by  aphasic  patients. 

Diagnosis.  Aphonia,  or  loss  of  voice,  should  not  be  confounded 
with  aphasia,  or  the  inability  to  remember  words. 

Paralysis  of  the  tongue,  or  inability  to  move  this  organ,  thereby 
interfering  with  articulate  language,  should  not  be  confounded  with 
aphasia,  which,  as  a  rule,  is  not  associated  with  paralysis  of  the 
tongue. 

Prognosis.  Controlled  entirely  by  the  cause.  If  the  result  of 
congestion  of  the  brain  or  a  syphilitic  tumor,  the  prognosis  is  favor- 
able. If  associated  with  hemiplegia,  the  clot  may  undergo  absorp- 
tion, and  recovery  follow.  If  associated  with  softening  of  the  brain, 
however,  the  disease  grows  progressively  worse. 

Treatment.  Depends  upon  the  cause,  which  must  be  energeti- 
cally treated,  as  the  aphasia  pursues  a  course  parallel  to  the  associ- 
ated malady.  Cases  not  associated  with  cerebral  softening  have 
regained  the  memory  of  words  by  a  course  of  carefully  conducted 
speech  lessons. 

Cases  of  aphasia  of  sudden  occurrence  are  strongly  diagnostic  of 
injury  due  to  a  spicula  of  bone  if  a  history  of  a  head  wound,  or  from 
the  pressure  of  a  clot,  and  the  operation  of  trephining  may  be  of 
benefit. 


DISEASES   OF   THE  CEREBRUM.  431 


VERTIGO. 


Synonym.    Dizziness. 

Definition.  Vertigo,  or  dizziness,  is  a  subjective  state,  in  which 
the  individual  affected  (subjective  vertigo),  or  the  objects  about  him 
(objective  vertigo),  seem  to  be  in  rapid  motion,  either  of  a  rotary, 
circular,  or  to-and-fro  character. 

Causes.  The  etiology  of  an  attack  of  vertigo  depends  upon  the 
particular  variety. 

Ocular  vertigo  results  from  the  paresis  of  one  or  more  of  the  ocular 
muscles,  eye-strain,  or  astigmatism. 

Aural  or  auditory  x^x^Ago,  ox  Meniere  s  disease,  results  from  disease 
of  the  semicircular  canals  and  cochlea.  Meniere's  disease,  properly 
so  called,  is  a  sudden  severe  vertigo,  the  result  of  either  a  hemorrhage 
or  a  serous  or  purulent  exudation  into  the  semicircular  canals. 

Gastric  vertigo  is  the  most  common  variety,  and  results  from  either 
stomachic  or  intestinal  dyspepsia,  disordered  hepatic  function,  or  con- 
stipation. "  The  mechanism  of  the  vertigo  is  complex.  There  are 
two  factors  :  one  consists  in  the  toxic  effect  of  the  imperfectly  oxidized 
materials  which  accumulate  in  the  blood ;  the  other  is  reflex.  An 
impression  made  on  the  end  organs  of  the  pneumogastric  in  the 
stomach  is  reflected  over  the  sympathetic  ganglia  "  (Bartholow). 

Nervous  vertigo  is  associated  with  migraine,  sick  or  nervous  head- 
ache, and  is  also  caused  by  physical  or  nervous  excesses,  also  by  the 
immoderate  use  of  tea,  coffee,  alcohol,  and  tobacco.  It  is  also  a  result 
of  many  of  the  organic  diseases  of  the  brain. 

Senile  vertigo  is  the  result  of  the  disordered  cerebral  circulation 
resulting  from  senile  changes  in  the  heart  and  vessels. 

Symptoms.  In  all  varieties  of  vertigo  the  symptom  of  a  sensa- 
tion of  objects  moving  around  the  patient,  or  the  patient  moving 
around  objects  vihAcYi  rGrxvaAXi  stationary,  is  present  in  some  degree. 
The  attack  oi giddiness  comes  on  suddenly,  with  an  indistinctness  of 
vision  and  slight  confusion  of  the  thoughts.  The  patient  may  fall 
unless  he  grasps  something  to  steady  himself.  Nausea  and  vomiting 
and  cardiac  palpitation  with  tinnitus  aurium  axe  often  associated  with 
the  vertiginous  sensations.      There  is  no  loss  of  consciousness. 

In  the  ocular  vertigo  the  attack  is  usually  the  result  of  reading, 
writing,  sewing,  or  other  close  application  of  the  eyes,  the  ordinary 


432  PRACTICE    OF    MEDICINE. 

symptoms  of  vertigo  being  preceded  by  headache,  nausea,  specks 
before  the  eyes,  and  pain  in  the  eyeballs. 

In  Meniere's  disease  the  vertigo  is  associated  with  serious  tinnitui 
aurtjtm,  and  the  vertiginous  sensations  are  of  various  forms,  such  as 
a  see-saw  movement,  a  gyratory  motion,  right  or  left ;  a  vertical  whirl, 
or  a  sensation  of  rising  and  falling  like  unto  the  swell  of  the  ocean. 
The  symptoms  are  of  long  duration,  becoming  marked  in  paroxysms. 
The  attack  of  aggravated  vertigo  is  so  sudden  and  overwhelming  at 
times  that  the  person  is  suddenly  thrown  to  the  ground  as  if  struck 
with  a  blow,  and  is  associated  with  nausea  and  vomiting.  As  the 
condition  continues,  the  character  of  the  individual  changes,  becoming 
morose,  irritable,  and  suspicious. 

Not  all  cases  of  Meniere's  disease  become  permanent,  but  it  may 
occur  in  isolated  attacks,  the  interval  being  free  from  all  sensa- 
tions. 

Gastric  vertigo  is  by  far  the  most  frequent  variety.  Persons  subject 
to  vertigo  of  this  kind  live  in  constant  dread  of  cerebral  disease,  which 
fear  frequently  results  in  true  melancholia. 

The  vertiginous  sensations  usually  occur  during  the  course  of  well- 
marked  and  long-standing  stomach  and  intestinal  disorders,  such  as 
pain  or  oppression  after  meals,  nausea,  pyrosis,  heartburn,  frequent 
eructations,  and  constipation  or,  rarely,  diarrhoea.  The  abdomen  is 
often  distended  with  flatus.  Great  pain  in  the  nucha  is  a  very  frequent 
occurrence.  The  attack  may  be  associated  with  either  hyperaemia  or 
anaemia  of  the  brain.  The  symptoms  are  not  constant,  but  recur  at 
intervals,  sometimes  remote,  at  others  very  close  to  each  other. 

In  nervous  vertigo  the  vertiginous  symptoms  are  usually  associated 
with  more  or  less  irritability  of  temper,  restlessness,  and  insomnia. 
The  onset  is  sudden,  after  some  one  of  the  etiological  factors.  In 
megrim  there  are  headache,  nausea,  and  vomiting.  This  form  of  ver- 
tigo often  precedes  or  replaces  the  epileptic  convulsion.  And  it  also 
often  precedes  softening  of  the  brain. 

In  senile  vertigo  the  vertiginous  symptoms  are  the  result  of  anaemia 
of  the  brain.  The  attacks  are  developed  by  any  exertion,  often  by 
merely  assuming  the  erect  posture.  There  is  a  swimming  sensation 
in  the  head,  darkness  falls  on  the  eyes,  with  a  sensation  of  chilliness 
and  prostration. 

Diagnosis.  The  diagnosis  of  the  various  forms  of  vertigo  can 
only  be  determined  after  a  close  study  of  the  history  and  course  of 


DISEASES   OF   THE  CEREBRUM.  433 

the  attack.  The  existence  of  organic  cerebral  disease  must  always  be 
kept  in  mind  in  solving  any  case. 

Prognosis.  This  will  be  influenced  by  the  variety  of  the  vertigo. 
The  prognosis  is  favorable  in  ocular  and  gastric  vertigo.  Unless  the 
result  of  organic  disease,  the  prognosis  is  good  in  nervous  vertigo. 
In  auricular  vertigo  the  prognosis  is  fair,  but  in  genuine  Meniere's 
disease  the  prognosis  is  unfavorable,  as  it  is  also  in  senile  vertigo. 

Treatment.  For  ocular  vertigo,  rest  for  the  eyes  and  properly 
adjusted  glasses. 

For  cases  of  Meniere's  disease,  rest  in  the  recumbent  position  and 
the  use  of  full  doses  of  quinince  sulphas,  gr.  x-xv  (0.6-1  Gm.),  daily 
until  cinchonism  occur,  then  omiting  the  drug  until  these  effects  dis- 
appear, and  if  no  improvement  is  observed,  begin  another  course, 
and  so  on  as  suggested  by  Charcot. 

For  gastric  vertigo  a  careful  regulation  of  the  diet.  At  the  begin- 
ning of  the  treatment  it  is  often  of  great  advantage  to  place  the 
patient  on  an  exclusively  milk  diet,  gradually  widening  the  variety 
as  improvement  occurs.  In  these  cases  a  course  of  arsenicuni  is 
often  serviceable.  If  the  digestion  be  torpid,  the  use  of  tmctura 
nucis  vomiccB  is  indicated.  If  the  bowels  are  constipated,  benefit  is 
obtained  from  exiractum  cascarce  sagradcE  fiuidutn. 

R.     Ext.  cascarse  sagr.  fld.,  ....  f^^j  30.  Cc. 

Glycerini, f^j  30.  Cc. 

Tinct.  card,  comp., f§ss  15.  Cc. 

Aquae  menthae  pip., f§ss  15.  Cc.  M. 

SiG. — One  teaspoonful  three  times  daily,  well  diluted. 

For  nervous  vertigo  the  removal  of  the  exciting  cause  and  the  use 
of  such  remedies  zsferrum,  quinina,  and  strychnina,  either  alone  or 
variously  combined. 

For  senile  vertigo,  a  highly  nutritious  but  easily  digested  diet,  the 
use  of  a  good  spiritus  fru^nenti  and  a  course  of  hydrargyri chloridum 
corrosivum,  or  arsenicum  with  tinctura  nucis  vomiccB,  or  a  long  course 
oi  spiritus  glonoini.     Prevent  flatulency  and  constipation. 

In  all  varieties  of  vertigo  the  habits  of  the  patient  must  be  most 
abstemious,  excluding  tobacco,  tea,  coffee,  highly  seasoned  foods, 
malt  liquors,  and  alcohol,  unless  particularly  indicated. 


28 


434  PRACTICli    OF    MEDICINE. 


MIGRAINE. 

Synonyms.  Megrim  ;  hemicrania ;  sick  headache  ;  bilious  head* 
ache;  blind  headache. 

Definition.  A  unilateral  paroxysmal  pain  in  the  head,  periodical, 
accompanied  by  nausea,  often  vomiting,  intolerance  of  light  and 
sound  and  incapability  of  mental  exertion,  the  brain  for  the  time 
being  temporarily  prostrated  and  disturbed. 

Causes.  In  the  majority  of  patients  the  nervous  predisposition 
to  migraine  is  inherited,  but  whether  inherited  or  acquired,  it  com- 
monly develops  about  puberty.  It  is  more  common  in  women  than 
in  men. 

Among  the  many  exciting  causes  are  disturbances  of  digestion, 
irritation  of  the  ovaries  or  uterus,  worry,  exacting  mental  labor,  sex- 
ual excesses  and  insufficient  sleep,  or  eye  strain.  The  causes  of 
many  attacks,  however,  are  wrapped  in  mystery,  as  with  the  best  of 
care  the  attacks  seem  to  have  a  periodical  course. 

Symptoms.  Attacks  of  migraine  occur  in  irregular  paroxysms, 
the  intervals  between  being  free  from  pain  or  nervous  disturb- 
ance. 

For  a  day  or  two  preceding  the  paroxysm  it  will  be  ascertained 
that  there  was  a  feeling  of  fatigue  or  mental  depression  without 
apparent  cause,  heaviness  over  the  eyes,  with  some  flatulency  and 
indigestion. 

The  attack  proper  is  ushered  in  by  chilliness,  yawning,  nausea,  often 
vomiting,  and  general  imiscular  soreness,  with  intolerance  of  light, 
flashes  before  the  eyes,  and  often  phantasms,  and  noises  in  the  ears 
with  incapability  for  vie7ital  exertion,  vertigo,  and  pain  of  a  sharp, 
shootifig  character,  of  great  intensity  and  persistency,  localized  most 
frequently  in  either  the  frontal,  temporal,  or  occipital  regions  of  the 
left  side  ;  at  the  same  time  there  is  tenderness  over  the  whole  side 
of  the  head.  Rarely  the  pain  is  felt  on  the  right  side,  and  still  more 
rarely  on  both  sides  at  the  same  time.  The  nausea  and  other  diges- 
tive symptoms  may  follow  the  onset  of  the  pain  instead  of  preceding 
it. 

There  is  more  or  less  disturbance  of  the  circulation,  temperature, 
and  secretions  of  the  painful  parts.  At  times  there  is  a  marked  con- 
traction of  the  vessels,  with  the  face  pale,  the  eyes  shrunken,  and  the 


DISEASES   OF  THE  CEREBRUM.  435 

pupils  dilated  ;  again,  the  vessels  may  be  dilated,  when  the  face  is 
flushed,  the  conjunctivae  injected,  and  the  pupils  contracted. 

The  urine  before,  during,  and  after  a  paroxysm  is  concentrated,  and 
it  may  be  that  the  excretion  of  uric  acid  is  associated  with  the  etiology 
of  migraine. 

Motion,  sound,  and  light  aggravate  the  acute  suffering. 

The  attack  may  continue  with  more  or  less  intensity  from  a  few 
hours  to  two  or  three  days,  the  average  duration  being  twenty-four 
hours. 

Diagnosis.  The  symptoms  are  so  characteristic  that  an  error 
seems  impossible.  It  may,  however,  be  confounded  with  anaemic 
headache,  hyperaemic  headache,  dyspeptic  or  bilious  headache,  and 
neuralgic  or  rheumatic  headache.  The  pains  of  organic  brain  disease 
must  be  excluded. 

Prognosis.  While  few  cases  of  true  migraine  are  permanently 
cured,  the  affection  is  free  from  danger  to  life.  In  a  fair  number  of 
cases  the  susceptibility  to  attacks  declines  as  the  person  advances  in 
years,  it  being  rarely  seen  after  fifty  years. 

"  Cases  of  migraine  of  the  ophthalmic  variety  appear  to  be  not 
rarely  followed  by  general  paralysis  of  the  insane"  (Herter). 

Treatment.  To  abort  an  attack  of  migraine  or  dispel  a  paroxysm 
after  its  onset,  rest  in  bed  in  a  quiet,  darkened  room,  with  abstinence 
from  food,  and  any  one  or  two  of  four  remedies  are  almost  infallible 
— one  is  a  hypodermic  injection  of  morphines  sulphas,  gr.  X  (0.016 
Gm.),  with  atropines  sulphas,  gr.  ^^  (0.00054  Gm.),  or  aniipyrine,  gr. 
XX  (1.3  Gm.),  repeated  in  an  hour  or  two;  or  phenacetin,  gr.  x  (0.6 
Gm.),  repeated  in  an  hour  or  two.  An  excellent  combination  for  the 
relief  of  the  paroxysm  is  : 

R .     Phenacetin,      gr.  xx  1.3  Gm. 

Caffeina  citrata, gr.  v  .3  Gm. 

Camphorse  monobrom., gr.  xx  1. 3  Gm.  M. 

Ft.  capsule  No.  x. 

SiG. — One  every  two  hours  until  relief. 

In  many  attacks  extracium  cannabis  indices  fiuidum,  Tt\^ij-iij 
(0.12-0.2  Cc),  every  half  hour  or  hour  for  a  number  of  doses,  alone 
or  combined  with  extractur7i  gelsemii  fiuidum,  in  the  same  dose, 
is  curative. 

A  combination  for  attacks  associated  with  contraction  of  the  vessels 
is — 


436  PRACTICE   OF    MEDICINE. 

R.      Polassii  broniid., pr.  xxx  2.  Gm. 

Morphinai  sulph. , gr.  ^'4^  .oi6  Gm. 

vel 

Codeinix;  sulph., gr.  j  .065  Gm. 

vel 

Tr.  opii  deodorat. , n\^xxx  .        2.         Cc. 

Aqux  menlh.  pip.,   ....    adf^ss  ad  15.         Cc.       M. 

SiG. — Repeated  p.  r.  n. 

The  local  use  o{  metithol  pencils  eases  the  pain,  and  the  inhalation 
of  spiritus  camphorae  is  agreeable. 

In  the  intervals  between  the  paroxysms  employ  measures  to  im- 
prove the  general  system,  and  to  overcome  as  far  as  possible  any 
of  the  etiological  factors.  For  this  purpose  extractiim  cannabis 
indica:,  gr.  %  (0.016  Gm.),  three  times  daily  for  several  months,  is 
highly  recommended. 

"  If  the  disposition  to  the  malady  is  inherited,  the  prophylaxis  is 
very  important,  and  should  include  diet,  exercise,  clothing,  and  the 
avoidance  of  all  those  conditions  which  tend  to  develop  an  abnormal 
excitability  of  the  nervous  system.  The  best  results  have  been  ob- 
tained from  galvanization  of  the  superior  ganglia  of  the  sympathetic  ; 
the  positive  pole  over  the  ganglion  and  the  negative  on  the  epigas- 
trium in  the  tetanic  (contraction  of  vessels)  form,  and  the  poles 
reversed  in  the  paralytic  (dilatation  of  vessels)  form  "  (Bartholow). 


ALCOHOLISM. 

"Varieties.     Acute  alcoholism  ;  chronic  alcoholism. 

Synonyms.     Acute  variety,  \.^xn\A&Vi\AZ.\  mania-a-potu. 

Chronic  variety,  delirium  tremens;  dipsomania,  or  oinomania. 

It  would  hardly  be  correct  to  consider  these  terms  interchangeable ; 
they  are  rather  names  applied  to  various  conditions  due  to  acute  or 
chronic  alcoholic  poisoning. 

Definition.  Alcoholism  is  the  term  used  to  designate  the  physi- 
cal and  mental  phenomena  induced  by  the  abuse  of  alcohol.  Alcohol 
is  a  poison,  but  becomes  a  much  more  dangerous  one  when  asso- 
ciated with  the  various  toxic  products  which  are  added  to  flavor  it. 

Teinulentia,  meaning  drunkenness,  or  alcoholic  intoxication; 
mania-a-potu  is  an  acute  mental  derangement,  occurring  in  those  of 
strong  neurotic  tendencies  ;  delirium  tremens  is  an  attack  of  delirium 


DISEASES   OF   THE  CEREBRUM.  437 

associated  with  tremors  in  persons  with  the  numerous  changes 
resuhing  from  chronic  alcoholism.  Delirium  tremens  frequently 
results  in  alcoholics  having  one  of  the  forms  of  nephritis,  preventing 
the  elimination  of  some  poison  developed  from  the  ingested  alcohol. 
Dipsomania,  or  oinomania,  an  alcoholic  insanity  in  which  an  indi- 
vidual at  longer  or  shorter  intervals  has  paroxysms  of  alcoholic 
desires,  between  which  he  neither  wishes  nor  craves  alcohol. 

Causes.  Predisposing  causes  are  influences  arising  from  unfavor- 
able moral,  social,  and  personal  conditions.     Heredity. 

Exciting  causes  are  the  immoderate  use  of  alcoholic  beverages,  of 
which  there  are  three  groups  :  i,  spirits,  or  distilled  liquors  ;  2,  wines, 
or  fermented  liquors,  and  3,  malt  liquors. 

Pathological  Anatomy.  Acute  Alcoholism.  The  brain  is  the 
seat  of  an  active  hypersemia  ;  the  mucous  membrane  of  the  stomach 
and  duodenum  is  markedly  injected  and  covered  with  a  ropy  mucus 
slightly  tinged  with  blood,  and  the  gastric  juice  is  altered  in  quality 
and  quantity.    The  kidneys  are  also  the  seat  of  an  active  hypersemia. 

Chronic  Alcoholism.  In  this  condition  there  are  no  organs  or 
tissues  which  do  not  present  morbid  changes.  The  gastro-intestinal 
mucous  membrane  presents  the  changes  of  chronic  catarrhal  in- 
flammation ;  the  liver,  the  first  organ  to  receive  the  poison  after 
the  stomach,  presents  the  changes  of  congestion,  cirrhosis,  or  fatty 
degeneration ;  the  kidneys  show  chronic  congestion  and  often 
the  changes  incident  to  chronic  interstitial  nephritis.  The  post- 
mortem results  found  in  twenty-five  cases  of  delirium  tremens  dying 
in  the  Philadelphia  Hospital  showed  fourteen  with  the  changes  of 
interstitial  nephritis,  eight  with  chronic  parenchymatous  nephritis, 
and  three  with  fatty  kidney ;  all  showed  chronic  gastric  catarrh  and 
changes  in  the  myocardium  and  the  arteries  of  the  heart,  brain,  and 
the  aorta.  The  muscular  structure  of  the  heart  may  undergo  fatty 
degeneration  and  the  vessels  the  senile  changes  of  the  aged.  The 
bram  structure  presents  the  changes  of  sclerosis  in  various  stages,  and 
there  may  be  chronic  meningitis  and  pachymeningitis  with  hematoma. 
The  nerves  are  altered,  atrophied,  and  hardened,  and  the  neuroglia, 
vessels,  and  ganglion  cells  of  the  spinal  cord  show  similar  changes. 

Symptoms.  Acute  alcoholisjn,  resulting  from  the  use  of  a  large 
quantity  of  alcoholic  fluid,  occurs  with  symptoms  of  mild  intoxica- 
tion to  drunkenness  passing  to  acute  delirium  and  acute  coma.  The 
condition  begins  with  a  period  of  exhilaration,  passing  to  semi- 


438  PRACTICE    OF    MEDICINE. 

delirium  and  ending  in  an  acute  coma,  when  the  breathing  is  ster- 
torous,  Xh^face  bhated  and  congested,  the  lips  swollen  and  purplis/t, 
the  pupils  contracted  or  dilated,  the  pulse  feeble  and  slow,  the  skin 
cold  and  clammy,  the  temperature  depressed,  and  frequently  control  oj 
sphincters  lost.    An  individual  so  affected  is  said  to  be  "  dead  drunk. " 

Cases  of  ordinary  drunkenness  do  not  often  pass  beyond  the  stage 
of  exhilaration,  ending  in  a  mild  coma  or  sleep. 

Mania-a-potu,  or  acute  alcoholic  delirium,  is  the  direct  result  of 
alcoholic  excess  in  those  engaged  in  a  sudden  debauch,  or  who 
have  drunk  alcoholic  beverages  very  "  hard  "  for  a  comparatively 
short  period.  The  individuals  grow  more  and  more  excitable, 
lose  all  desire  for  food,  are  unable  to  sleep,  become  the  prey  of 
horrible  hallucinations, — "the  horrors," — finally  terminating  in  mania 
which  resembles  delirium  tremens  in  all  save  the  tremor,  which  is 
absent. 

Delirium  Tretnens.  In  the  majority  of  instances  delirium  results 
from  a  prolonged  debauch,  in  an  old  drinker,  with  abstinence  from 
proper  food.  It  begins  by  an  increased  tremor,  insomnia,  irritable, 
excited  manner,  followed  by  the  characteristic  hallucinations  and 
illusions,  during  which  snakes  and  other  forms  of  repulsive  reptiles  are 
seen,  causing  the  most  intense  horror  and  abject  fear;  it  is  a  busy 
delirium,  the  patient  unable  to  remain  quiet.  There  also  occur  illu- 
sions of  smell  and  hearing.  This  marked  excitement  is  followed  by 
great  depression,  the  skin  is  cold  and  clammy,  the  pulse  feeble,  the 
muscular  system  weak,  the  mind  in  a  condition  of  coma-vigil,  and 
if  continued,  a  febrile  condition,  typhoid  in  character,  with  stupor  or 
coma,  develops.  Uramic  symptoms  frequently  complicate  the  con- 
dition, the  temperature  suddenly  bounding  to  103°  F.,  to  104°  F.,  or 
105°  F.,  with  albumin  and  casts  in  the  scanty  urine. 

The  ordinary  duration  of  an  attack  of  delirium  tremens  is  about 
two  weeks  in  those  who  recover,  although  death  may  occur  at  any 
time  from  cardiac  failure,  uraemia,  or  alcoholic  pneumonia.  Indeed, 
patients  sometimes  die  suddenly  in  whom  improvement  had  begun. 
Convalescence  dates  from  the  beginning  of  refreshing  sleep,  the 
patient  awakening  with  a  clear  mind  and  desire  for  food.  Should  the 
delirium  subside,  but  the  patient  continue  to  mutter  and  pick  at  the 
bed-clothing,  the  tongue  become  dry  and  cracked,  and  the  regurgita- 
tion of  dark  brownish  and  bilious  matter  occur,  the  condition  is 
critical  and  an  early  fatal  termination  may  be  expected. 


DISEASES   OF  THE   CEREBRUM.  439 

Dipsomania,  or  oinomania,  is  the  inherited  or  acquired  mental  con- 
dition which  craves  the  drinking  of  intoxicating  liquors.  This  is  a 
true  mental  disease.  It  manifests  itself  in  periodical  attacks  of  exces- 
sive indulgence  in  alcoholic  drinking,  or  this  symptom  of  the  sad 
disease  may  be  replaced  by  other  irresistible  desires  of  an  impulsive 
kind,  such  as  lead  to  the  commission  and  repetition  of  various  crimes, 
the  gratification  of  other  depraved  appetites,  robbery,  or  even  homi- 
cide.    Imbecility  and  dementia  frequently  result. 

The  paroxysms  at  first  occur  at  long  intervals,  but  gradually  the 
intervals  become  shorter  and  shorter  until  the  individual  entirely  sur- 
renders himself  to  alcoholic  and  other  excesses. 

Chronic  Alcoholism.  The  condition  to  which  this  term  has  been 
given  is  truly  a  disease.  It  is  the  result  of  the  continued  use  of  alco- 
holic beverages  until  one  or  more  of  the  morbid  organic  changes 
have  occurred.  These  persons  are  markedly  dyspeptic,  with  coated 
tongue,  fetid  breath,  and  early  morning  vomiting,  straining,  or  retch- 
ing, attended  with  much  distress.  There  is  a  gradually  developing 
muscular  tremor,  progressing  to  the  ataxic  gait.  Insomnia  or  restless 
sleep  is  frequent.  The  face  may  either  become  pallid,  flabby,  and 
bloated,  with  an  imbecilic  expression,  or  swollen,  rough,  and  dusky, 
with  great  bladders  under  the  eyes,  with  yellow  injected  conjunc- 
tivae. There  is  headache,  vertigo,  and  attacks  of  hallucinations ; 
the  memory  grows  weaker,  the  judgment  less  accurate,  the  moral 
sense  blunted,  and  the  will  power  weak  and  erratic.  These  and 
many  other  symptoms  add  to  the  distress  of  the  individual,  which 
he  attempts  to  overcome  by  the  use  of  more  and  more  of  the  poison. 

Diagnosis.  Profound  drunkenness,  or  alcoholic  coma,  may  and 
often  is  confounded  with  apoplectic  and  uremic  coma.  Von  Wede- 
kind  suggests  the  following  method  for  diagnosing  drunkenness: 
"  By  simply  pressing  on  the  supraorbital  notches  with  a  steadily 
increasing  force  you  may,  with  certainty  of  success,  bring  an  un- 
conscious alcoholic  to  his  senses,  and  thus  differentiate  between  alco- 
holic and  other  comas." 

The  symptoms  of  chronic  alcoholism  often  bear  a  close  resem- 
blance to  the  following  maladies:  General  paralysis,  disseminated 
sclerosis,  paralysis  agitans,  locomotor  ataxia,  cerebral  and  spinal 
softening,  epilepsy,  dementia  chronica,  and  nervous  dyspepsia. 

In  individuals  whose  habits  are  secret  the  question  of  diagnosis  is 
attended  with  considerable  difficulty.     Anstie  lays  much  stress  upon 


440  PRACTICK    OF    MEDICINE. 

the  importance  of  the  following  four  points,  diagnostic  of  chronic 
alcoholism  :  insomnia,  tnortiing  vomiting,  muscular  tremor,  and  cause- 
less mental  restlessness. 

Prognosis.  In  acute  alcoholism  the  prognosis  is  good  if  the 
patient  is  manageable. 

In  chronic  alcoholism  the  organic  changes,  the  direct  result  of  the 
alcoholic  habit,  tend  to  shorten  life  by  the  production  of  fatty  heart, 
Blight's  disease,  insanity,  impotence,  epilepsy,  melancholia,  and 
organic  brain  diseases.  The  danger  in  delirium  tremens  is  heart 
failure  or  deepening  coma.  The  association  of  chronic  nephritis  with 
delirium  tremens,  perhaps  its  cause,  must  always  be  taken  into  account 
in  determining  a  prognosis.  Acute  lobar  pneumonia  is  a  very  fatal 
complication  in  all  forms  of  alcoholism. 

Treatment.  In  deciding  upon  a  plan  of  medication  for  any  of  the 
varieties  of  alcoholism,  the  condition  of  the  kidneys,  heart,  and  vessels 
must  be  considered.  The  treatment  of  a  case  of  ordinary  drunken- 
ness requires  little  consideration,  as  the  rapid  elimination  of  the 
alcohol  soon  occurs  if  its  ingestion  be  stopped.  Liquor  ammonii 
acetatis  in  large,  frequently  repeated  doses,  assists  the  elimination  of 
the  poison. 

For  inania-apotu  the  immediate  and  complete  withholding  of  alco- 
holic beverages  is  essential  for  its  successful  treatment.  If  the  stom- 
ach will  tolerate  food, — and  usually  it  will, — milk  diluted  with  liquor 
calcis,  or  Seltzer  water,  or  hot  beef  tea  strongly  seasoned  with  capsi- 
cum, should  be  administered  every  hour  or  two  in  small  amounts. 

The  appetite  is  stimulated  by  the  use  of  a  combination  like — 

K .     Tinct.  nucis  vomicse, f^'^  ^5-  Cc. 

Tinct.  capsici, f  ^  iv  15.  Cc. 

Tinct.  cinchonae  comp.,     .    .    .    .  f3  ij  60.  Cc.  M. 

SlG. — One  teaspoonful,  diluted,  every  two  or  three  hours. 

This  stomachic  stimulant  may  be  alternated  with  spiritus  ammonia 
aromaticus,  f3j  (4CC.),  given  in  hot  milk,  with  advantage  to  the  heart 
and  nervous  irritability.  The  bowels  should  be  moved  at  once  by 
the  administration  of  an  enema: 

R.     Magnesii  sulph., .^ij  60.  Gm. 

Glycerin!, ,    .    .    .  f,|j  30.  Cc. 

Aquae  bul f5iv  120.  Cc. 


DISEASES   OF  THE  CEREBRUM.  441 

and  the  kidneys  stimulated  by  full  doses  of  spiritus  cetheris  nitrosi  if 
the  patient  will  swallow,  and,  if  not,  by  the  hypodermic  use  oi  caffeince 
citrata.  The  restlessness,  insomnia,  delirium,  and  visual  and  auditory 
hallucinations  are  usually  controlled  with  chloral,  and,  on  account  of 
the  gastric  torpor  and  catarrh  interfering  with  the  prompt  absorption 
of  medicaments,  is  best  given  by  the  bowel : 

R.     Chloral, gr.  xx-xxx  1-3-2  Gm. 

Infus.  digitalis, f^j  30.  Cc. 

Repeated  in  two  hours,  in  milk. 

If  enema  cannot  be  used,  chloral  or  trional,  gr.  xxx  (2  Gm.),  may  be 
given  by  mouth,  or  resort  may  be  had  to  hypodermic  medication  if 
there  is  urgency,  using  niorphince sulphas,  gr.  }i-]A,  (0.016-0.023  Gm.), 
combined  with  atropincB  sulphas,  gr.  y^  (0.00065  Gm.),  or  hyoscmcB 
hydrobromas,  gr.  ^^  (0.00065  Gm.).  If  the  attack  be  associated  with 
symptoms  of  cardiac  depression,  use  brisk  friction,  hot  alcohol  and 
water  sponging,  artificial  warmth,  stimulating  enemata,  and  the  hypo- 
dermic administration  of  strychnines  sulphas,  gr.  •5'5-^V  (0003- 
0.002  Gm.),  repeated,  or  caffeina  citrata,  gr.  iij  (0.2  Gm.),  or  digitalis 
"  If  chloral  be  inadmissible  by  reason  of  weakness  of  the  circulation, 
paraldehydton  may  be  substituted,  in  doses  of  from  f^ss-j  (2-4 
Cc),  repeated  at  intervals  of  from  one  to  two  hours  until  quietude  is 
produced  "  (J.  C.  Wilson). 

If  one  or  two  medicinal  doses  of  the  selected  sedative  drug  does 
not  produce  quiet  and  sleep,  be  most  cautious  in  repeating,  remem- 
bering that  the  patient  is  suffering  from  the  depressing  effects  of  a 
cardiac  and  nervous  poison,  which  is  best  combated  by  eliminating 
action  on  skin,  bowels,  and  kidneys,  and  the  administration  of  food. 

An  attack  of  acute  alcoholism,  or  mania-a-potu,  may  often  be 
aborted  with  irional,  gr.  xxx  (2  Gm.),  repeated  in  two  hours,  or 
chloralamid,  gr.  xxx-xl  (2-2.6  Gm.),  repeated.  Excellent  and  prompt 
results  follow  the  use  of  a  hot-air  bath  until  profuse  sweating. 

For  the  collapse  following  a  lethal  dose  of  alcohol,  the  stomach 
should  be  immediately  emptied  by  emetics  or  the  stomach  tube  or 
pump  and  the  organ  washed  out  with  warm  water  or  coffee,  the 
patient  placed  in  the  recumbent  position,  and  surrounded  with  arti- 
ficial warmth,  hot  frictions  to  the  lower  extremities,  the  use  of  artificial 
respiration  or  the  use  of  faradism  to  the  thorax,  inhalations  of 
ammonia,   hypodermic   injections    of   strychnince    sulphas,   spiritus 


442  PRACTICE    OF    MEDICINE. 

glonoini,  digitalis,  strophanthus,  or  airopincE  su/p/tas.  "  The  flagging 
heart  may  be  stimulated  by  occasionally  tapping  the  prascordia  with 
a  hot  spoon — Corrigan's  hammer"  (J.  C.  Wilson). 

Delirium  Tremens. — The  patient  should  be  isolated,  have  a  skillful, 
sensible  nurse,  have  the  quantity  of  alcohol  entirely  withdrawn,  or 
greatly  reduced,  have  the  stomach  washed  out  daily,  be  supplied  with 
easily  digested  nutritious  diet,  and  action  on  the  skin,  kidneys,  and 
bowels,  with  remedies  to  combat  the  excited  nervous  system.  For 
this  Litter  purpose  no  one  combination  is  comparable  with  hypo- 
dermic injections  of  viorphince  sulphas,  gr.  ^(o.oi6  Gm.),  with 
atropines  sulphas,  gr.  yj^  (0.00065  Gm.),  or  hyoscince  hydrobromas, 
gr.  yjjj  (0.00065  Gm.),  repeated,  or  the  use  oi  chloral  ox  trional  hy  the 
bowel  or  by  the  stomach  if  the  patient  can  or  will  swallow,  or  the 
stomach  is  not  too  irritable  : 

B.     Chloral, giv  15.  Gm. 

Tr.  capsici,      f  _:^  ij  8.  Cc. 

AquLi;  menth.  pip.,     .     q.  s.  ad  f5vj  ad  180.  Cc. 

Sin. — Tablespoonful  every  two  hours  until  sleep,  alternated  with  a  cup 
of  hot  beef-tea,  to  whicli  has  been  added  a  bolus  of  capsicum,  gr.  xx 
(1.3  Gm.). 

Care  is  necessary  that  a  condition  of  coma  be  not  produced  by  the 
remedies  mentioned,  never  giving  more  than  two  doses  within  six 
hours,  but  pushing  hot  liquid  diet  and  atropine  sulphas,  gr.  ^j  (o.ooi 
Gm.),  with  strychnines  nitras,  gr.  -^^  (0.002  Gm.),  by  the  hypodermic 
method,  as  experience  has  proven  that  these  drugs  given  three  times 
daily  in  reducing  doses  are  the  physiological  antidote  to  the  alcoholic 
toxin. 

For  depression  and  cardiac  weakness,  the  internal  use  of  any  one 
of  the  following  drugs  is  serviceable :  Strychnines  sulphas,  caffeincB 
citraia,  spiritus  chloroformi,  ammonii  carbonas,  tinctura  strophanthus, 
or  digitalis. 

For  the  stomach  atony  use  the  nux  and  capsicum  mixture  men- 
tioned above  and  washing  out  the  stomach  every  day  or  two. 

Other  nervous  sedatives  recommended  are  paraldehydutn,  chlor- 
alainid,  and  the  bromides. 

Strict  attention  must  be  given  to  the  skin,  bowels,  and  kidneys.  If 
the  heart  is  not  depressed,  the  cautious  use  of  the  hot-air  bath  or  hypo- 
dermic injections  of  pilocarpines  hydrochloras,  gr.  ^  (0.02  Gm.), 
repeated  at  the  onset  of  the  mania. 


DISEASES   OF  THE  CEREBRUM.  443 

Chronic  Alcoholism. — The  combine  of  symptoms  termed  chronic 
alcoholism  are  the  direct  result  of  the  continuous  action  of  a  toxic 
principle,  and  no  success  of  even  a  temporary  kind  can  be  expected 
unless  the  poison  be  withdrawn.  The  rapidity  with  which  this  can  be 
accomplished  is  a  question  for  the  skill,  judgment,  and  experience  of 
the  physician  to  determine  ;  the  chief  obstacle  to  its  success  will  be 
found  moral  rather  than  physical.  Next  to  the  disuse  of  alcohol  is 
the  question  of  diet.  Progress  will  be  made  as  the  appetite  and 
digestion  improve,  and  great  attention  should  be  given  to  these.  The 
general  health  will  also  be  benefited  by  fresh  air,  exercise,  mental 
occupation,  and  cold  or  tepid  sponging  and  an  occasional  hot  bath  at 
bedtime.  For  the  combination  of  symptoms  of  spirit-craving,  morn- 
ing vomiting,  muscular  tremor,  mental  restlessness,  and  insomnia,  no 
drug  is  comparable  with  strychnincB  nitras,  either  hypodermically 
twice  daily,  or,  what  is  preferable,  by  the  stomach  to  secure  its  local 
action  on  the  mucous  membrane.  If  the  insomnia  be  persistent  in 
spite  of  the  foregoing  treatment,  the  temporary  use  may  be  made  of 
such  remedies  as  chloral,  morphince  sulphas,  paraldehyduin,  or  trioiial. 
In  many  cases  it  is  desirable,  for  its  mental  effect,  if  no  other, 
administer  what  the  patient  terms  a  substitute  for  his  alcoholic 
beverages.     The  following  is  a  good  combination  for  that  purpose  : 

R.     Tincturje  nucis  vomicae,     .    .    .  f5ss  i5.Cc. 

Tincturse  capsici, f^^^  ^5-  Cc. 

Ext  lupulini  fld  , f.^iij  90-  Cc. 

Inf  gent,  co  , f^ij  60.  Cc.  M. 

SiG. — Dessertspoonful  three  or  four  times  daily,  well  diluted. 

For  the  anaemia,  loss  of  strength,  and  mental  debility,  benefit  may 
follow  the  use  of  syrupiis  hypophosphitis  cum  strychnince. 

Dipsomania. — The  management  of  these  cases  is  much  the  same 
as  has  already  been  mentioned  for  chronic  alcoholism,  although  the 
strychnines  sulphas  treatment  should  be  given  the  preference. 


HEAT  STROKE. 

Synonyms.      Insolation  ;    sunstroke ;    thermic    fever  ;    coup-de- 
soleil;  heat  exhaustion. 

Definition.     A   depression    of   the  vital   powers,  the    result  of 


444  PRACTICK    OF    MEDICINE. 

exposure  to  excessive  heat.  The  condition  manifests  itself  as  acute 
meningitis  (rare),  heat  exhaustion  (common),  and  as  true  sun- 
stroke. 

Causes.  Exposure  to  the  influence  of  excessive  heat,  either  to  the 
direct  rays  of  the  sun  or  artificial  heat  in  confined  quarters,  or  diffused 
atmospheric  heat  without  proper  ventilation. 

Among  the  predisposing  causes  which  act  by  lessening  the  power 
of  the  system  to  resist  the  heat,  are  great  bodily  fatigue,  overcrowd- 
ing, and  intemperance. 

Pathological  Anatomy.  The  action  of  the  heat  upon  the 
system  is  so  sudden,  and  the  malady  so  rapid  in  its  course,  that 
structural  changes  have  not  developed.  The  left  ventricle  is  firmly 
contracted  (Wood).  The  right  heart  and  vessels  are  gorged  with 
dark  fluid  blood.  All  the  tissues  and  organs  of  the  body  are  in  a 
state  of  great  venous  congestion.  The  blood  is  dark,  thin,  and 
either  but  feebly  alkaline  or  decidedly  acid,  and  its  power  of  co- 
agulability is  destroyed.  The  postmortem  rigidity  is  early  and 
marked. 

Symptoms.     Depending  upon  the  variety. 

Acute  meningitis,  the  result  of  exposure  to  heat,  has  symptoms 
similar  to  those  due  to  other  causes. 

Heat  exhaustion  develops  with  a  rapid  feeling  of  weakness  and 
prostration,  the  surface  cool,  XhQ  face  pale,  the  voice  weak,  ihe  pulse 
rapid  and  feeble,  the  respiration  increased,  the  vision  growing  dim 
and  indistinct,  noises  develop  in  the  ears,  the  individual,  overcome, 
becoming  partially  or  completely  unconscious.  In  some  cases  the 
attack  of  prostration  is  sudden,  the  person  falling  unconscious,  with 
perhaps  convulsions  or  tremors,  and  shrunken  features. 

Sunstroke.  The  symptoms  developing  suddenly,  with  or  without 
prodromata,  are  insensibility,  with  or  without  delirium  or  convulsions 
or  paralysis,  \.h.&  surface  flushed  Tind.  hot,  the  conjunctives  injected,  and 
breathing  either  rapid  and  shallow  or  labored  and  stertorous,  thept/lse 
quick  and  either  bounding  or  weak,  and  the  tonperature  in  the  axilla 
ranging  from  105°  to  108°,  to  1 10°,  with  suppression  of  all  glandular 
action.  Death  occurring,  the  result  of  asphyxia,  or  from  a  slow 
failure  of  respiration  and  cardiac  action. 

Diagnosis.  It  is  of  great  importance,  therapeutically,  to  distin- 
guish at  once  between  attacks  of  sunstroke  and  heat  exhaustion. 
Cases  of  sunstroke  are  to  be  differentiated  from  cerebral  hemorrhage 


DISEASES   OF   THE   CEREBRUM.  445 

and  alcoholic  insensibility,  for  which  purpose  the  clinical  thermometer 
is  indispensable. 

Prognosis.  Attacks  of  heat  exhaustion,  if  properly  and  promptly 
treated,  favorable.  The  prognosis  of  sunstroke,  or  heat-fever,  is 
unfavorable  in  the  majority  of  cases,  death  resulting  in  from  half  an 
hour  to  several  hours.  Unfavorable  indications  are,  increased  tem- 
perature, cardiac  failure,  convulsions,  absent  reflexes,  followed  by 
complete  muscular  relaxation. 

Favorable  indications  are,  decline  in  surface  heat  and  axillary  or 
rectal  temperature,  stronger  pulse,  increased  depth  of  respirations, 
restored  reflexes,  and  return  of  consciousness. 

Sequelae.  If  recovery  follow  either  variety,  any  one  of  the  fol- 
lowing conditions  may  result :  headache,  vertigo,  insomnia,  epilepsy, 
mental  enfeeblement,  and  monoplegia,  paraplegia,  or  hemiplegia. 

Treatment.  Cases  of  heat  exhausiio7i  are  successfully  treated  by 
placing  the  patient  in  the  recumbent  position,  with  the  head  low  and 
the  use  of  stimulants.  If  able  to  swallow,  administer  at  once  spiritus 
vini  gallici,  ^ss-j  (15-30  Cc),  with  tinctura  opii  deodorata,  Tti^xv-xxx 
(1-2  Cc),  to  be  repeated  p.  r.  n. ;  and  spiritus  anutiotiice  aromaticus, 
f3j  (4  Cc),  in  hot  water  or  milk  every  half  hour.  If  he  be  unable 
to  swallow,  the  remedies  may  be  thrown  into  the  rectum,  or  spiritus 
frumenti,  strychnincE  sulphas,  and  tinctura  digitalis  can  be  used  hypo- 
dermically.  As  convalescence  occurs,  tonic  doses  of  quinines  hydro- 
chloras  and  strychnines  sulphas  should  be  prescribed. 

For  sunstroke,  the  indications  for  treatment  are  the  very  opposite. 
The  patient  is  in  imminent  danger  from  the  extraordinary  temperature, 
and  measures  to  reduce  it  must  at  once  be  instituted.  Of  these  none 
give  such  excellent  results  as  rubbing  with  ice,  or  the  cold  bath  or  cold 
pack,  and  cold  affusions,  cold  enetnata,  and  the  hypodermic  use  of 
quinines  sulphas,  or  antipyrin.  The  tendency  to  subsequent  rise  of 
temperature  is  met  by  wrapping  the  patient  in  a  wet  sheet,  or  the 
repetition  of  the  hypodermics  mentioned  if  consciousness  has  not 
been  regained,  when  they  can  be  given  by  the  mouth.  If  convulsions 
and  restlessness  occur,  the  hypodermic  use  of  morphines  sulphas,  gr. 
X~K  (0.016-0  032  Gm.),  cautiously  repeated,  is  successful,  or  chloral 
and  the  bromides  by  the  rectum.  If  symptoms  of  depression  occur, 
the  stomachic,  rectal,  or  hypodermic  administration  of  stimulants  is 
indicated,  and  strychnines  sulphas,  gr.  ^-^  (0.0025  Gm.)  repeated  half 
hourly  by  the  hypodermic  method. 


446  PRACTICE    OF    MEDICINK. 

For  convalescence,  use  quinincB  hydrochloras; sirychninct  mlphas 
or  fi-rrum. 

ACUTE  HYDROCEPHALUS. 

Synonyms.     Acquired  hydrocephalus  ;  serous  apoplexy. 

Definition.  Strictly  speaking,  hydrocephalus  signifies  water  in 
the  brain  ;  but  it  is  here  restricted  to  the  presence  of  a  serous  fluid  in 
the  arachnoid  spaces,  in  the  pia  mater,  in  the  ventricles,  and  in  the 
brain  substance  (cedema) ;  characterized  by  the  more  or  less  sudden 
development  of  cerebral  excitation,  followed  by  depression  and 
usually  death. 

Causes.  Most  common  between  the  ages  of  one  and  five, 
although  it  may  occur  at  any  age.  "  The  predominance  of  the  nerv- 
ous system  in  the  bodily  conformation  "  is  a  strong  predisposing 
cause.  Among  the  exciting  causes  are  unfavorable  hygienic  con- 
ditions, dentition,  eruptive  fevers,  blows  on  the  head,  mechanical 
causes  preventing  the  return  of  the  blood  from  the  venee  Galeni  and 
the  right  sinus,  compression  of  the  jugular  vein,  diseases  of  the  right 
heart,  and  Bright's  disease. 

Pathological  Anatomy.  The  effusion  may  be  limited  to  the 
ventricles,  although  there  is  usually  considerable  distention  of  the 
subarachnoid  spaces  and  oedema  of  the  pia  mater  and  neighboring 
portions  of  the  brain,  whence  results  more  or  less  softening,  especially 
around  the  ventricles.  The  choroid  plexus  is  hyperaemic,  and  may 
be  the  seat  of  minute  extravasations. 

Symptoms.  There  are  three  varieties  of  acute  hydrocephalus 
with  characteristic  symptoms,  to  wit :  comatose,  convulsive,  and  the 
ordifiary. 

Comatose  variety,  known  also  as  "serous  apoplexy,"  begins 
abruptly  with  the  phenomena  of  apoplexy,  the  result  of  the  sudden 
effusion.  The  pressure  is  usually  so  great  on  the  medulla  oblongata 
that  it  ceases  to  functionate,  death  resulting  in  a  few  hours,  rarely 
lasting  several  days. 

Convulsii'e  variety,  the  result  of  Bright's  disease  or  a  general 
dropsy,  is  ushered  in  with  headache,  nausea,  and  vomiting,  followed 
in  a  day  or  two  with  convulsions,  passing  into  coma,  which  usually 
terminates  fatally,  although  rarely  a  remission  may  precede  death  for 
a  day  or  two. 


DISEASES   OF  THE  CEREBRUM.  447 

Ordinary  variety,\Sx&  most  common  in  children,  begins  with  fever- 
ishness,  headache,  vertigo,  photophobia,  restlessness,  nocturnal  deli- 
rium, insomnia,  twitching,  and  spasmodic  contractions  of  the  muscles 
and  great  hyperaesthesia  of  the  skin.  Such  symptoms  continue  for 
several  days,  when  convulsions  occur,  followed  by  death,  or  a  con- 
tinuance of  the  symptoms,  followed  by  rigidity,  stupor,  and  death. 

Prognosis.     Unfavorable. 

Treatment.  An  attempt  may  be  made  to  remove  the  fluid  by 
diuretics  and  full  doses  of  potassii  iodidutn. 


CONGENITAL   HYDROCEPHALUS. 

Synonym..     Chronic  hydrocephalus  (?). 

Definition.  An  excessive  accumulation  of  the  cerebro-spinal 
fluid — a  cerebral  dropsy — in  the  ventricles — internal  hydrocephalus, 
or  in  the  meshes  of  the  pia  arachnoid — external  hydrocephalus,  or  in 
both — mixed  hydrocephalus ;  characterized  by  enlargement  of  the 
head  and  more  or  less  pronounced  nervous  phenomena. 

A  disease  of  infants  or  very  young  children. 

Causes.  Imperfect  or  arrested  development  of  the  brain  or  its 
membranes.  Occurs  in  the  offspring  of  tubercular,  scrofulous,  or 
syphilitic  parents.  Inflammatory  changes  in  the  ventricles  and 
ependyma. 

Pathological  Anatomy.  Enlargement  of  the  head  is  the  chief 
external  pathological  condition,  although  there  is  no  constant  ratio 
between  the  size  of  the  head  and  the  amount  of  fluid,  the  quantity 
varying  from  an  ounce  to  a  pint  or  more.  The  liquid  is  transparent, 
of  a  straw  color,  containing  a  small  amount  of  albumin  and  chloride 
of  sodium. 

If  the  quantity  of  fluid  be  small,  the  ventricles  are  simply  distended  ; 
if  the  amount  be  large,  the  optic  thalami  and  corpus  striatum  are 
depressed  and  flattened,  the  roof  of  the  ventricles  thinned,  and  the 
foramen  of  Monro  is  greatly  enlarged.  The  enlargement  of  the  head 
may  occur  before  birth  and  impede  or  prevent  natural  delivery,  or  the 
head  may  be  normal  at  birth  and  increase  afterward.  As  enlargement 
progresses,  the  bones  are  so  thinned  as  to  be  translucent,  the  fonta- 
nelles  and  sutures  are  widened,  the  lateral  portions  of  the  cranium 
project,  the  forehead  bulges  out  over  the  eyes,  and  the  orbital  plates 


448  PRACTICE    OK    MEDICINE. 

are  depressed,  forcing  the  eyes  outward  and  downward,  producing  a 
variety  of  exophthalmos  ;  the  head  has  an  irregular,  triangular  shape, 
the  base  of  the  triangle  being  the  top  of  the  head.  The  scalp  being 
stretched  by  the  pressure  within,  becomes  tense  and  thin,  and  but 
scantily  covered  with  hair  ;  the  veins  which  ramify  in  it  are  unusually 
prominent  and  large,  and  the  entire  head  is  elastic  on  pressure,  from 
the  amount  of  liquid  beneath. 

Hilton,  in  Rest  and  Pain,  says  :  "  In  almost  every  case  of  internal 
hydrocephalus  which  I  have  examined  after  death  I  found  that  this 
cerebro-spinal  opening  (between  the  fourth  ventricle  and  the  spinal 
canal)  was  so  completely  closed  that  no  cerebro-spinal  fluid  could 
escape  from  the  interior  of  the  brain  ;  and,  as  the  fluid  was  being 
constantly  secreted,  it  necessarily  accumulated  there,  and  the  occlu- 
sion formed,  to  my  mind,  the  essential  pathological  element  of  internal 
hydrocephalus." 

Symptoms.  The  increased  size  of  the  head,  with  the  emaciated 
condition  of  the  child,  who  seemingly  eats  well,  is  what  first  attracts 
the  attention.  The  head  appears  too  heavy  ;  the  eyes  are  prominent 
and  have  a  downward  direction  ;  the  face  is  devoid  of  expression,  old 
and  wrinkled,  the  voice  feeble ;  the  mental  development  is  not  in 
keeping  with  the  age.  When  the  period  for  standing  or  walking 
arrives,  the  power  is  found  wanting.  The  further  history  is  but  a  con- 
tinuation and  exaggeration  of  this,  until  convulsiofis  occur,  which 
sooner  or  later  terminate  fatally. 

The  course  of  congenital  hydrocephalus  is  usually  slow,  but  pro- 
gressively worse.  The  majority  terminate  within  the  first  year  ;  cases 
are  recorded,  however,  of  ten  and  fifteen  years'  duration. 

Diagrnosis.  In  rachitis  the  volume  of  the  head  is  increased,  due, 
in  part,  at  least,  to  a  deposit  of  calcareous  matter  on  the  exterior  of 
the  cranial  bones.  Rachitis  may  be  mistaken  for  hydrocephalus  in 
cases  in  which  the  amount  of  liquid  is  small.  The  differential  di3.gnosis 
is  based  on  the  shape  of  the  head — round  in  rachitis,  square  or  tri- 
angular or  with  prominences  in  hydrocephalus,  with  the  persistent 
downward  direction  of  the  eyes  and  the  elasticity  of  the  head  on 
pressure. 

Prognosis.  Unfavorable.  Arrest  of  progress  and  even  cures 
have  been  reported.  Spontaneous  cures  have  been  reported  fol- 
lowing the  accidental  discharge  of  the  fluid.  But  such  reports  are 
exceptional. 


DISEASES   OF  THE   SPINAL   CORD.  449 

Treatment.  The  use  of  the  finest  aspirator  needle  to  evacuate 
the  fluid  is  fully  justifiable.  The  proper  situation  for  the  puncture  is 
the  coronal  suture,  about  an  inch  or  an  inch  and  a  half  from  the 
anterior  fontanelle.  Firm  but  gentle  compression  of  the  cranium 
with  adhesive  strips  should  be  made  during  the  escape  of  the  fluid 
and  afterward.  A  few  ounces  of  fluid  only  should  be  withdrawn  at  a 
time.     The  internal  use  oi potassii  iodidum  is  recommended. 

All  measures  which  tend  to  promote  the  constructive  metamor- 
phosis are  to  be  employed. 


DISEASES  OF  THE  SPINAL  CORD. 


SPINAL  HYPEREMIA. 

Synonyms.     Spinal  congestion  ;  plethora  spinalis. 

Definition.  An  abnormal  fullness  of  the  vessels  of  the  meninges 
and  cord :  active  when  an  arterial  hyperaemia ;  passive  when  a  venous 
hyperaemia;  characterized  by  pain  in  the  back,  with  more  or  less 
pronounced  disorders  of  sensation  and  locomotion. 

Causes.  Cold  and  exposure ;  arrested  menses ;  arrest  of  a  habitual 
haemorrhoidal  discharge ;  malaria  ;  protracted  erect  posture  ;  injuries 
to  the  back  ;  certain  spinal  poisons,  as  strychnina,  picrotoxinum,  and 
alcoholic  excesses. 

Pathological  Anatomy.  Active.  The  post-mortem  appear- 
ances are  congestion  of  the  meninges  and  cord,  the  same  vessels 
supplying  both,  with  numerous  points  of  extravasation,  due  to  the 
rupture  of  capillary  vessels.    The  spinal  fluid  is  increased  in  amount. 

Passive,  A  general  bluish  discoloration,  owing  to  the  abnormal 
fullness  of  the  large  anastomosing  vessels  ;  the  spinal  fluid  somewhat 
increased. 

Symptoms.  Active.  Dull /am  in  the  dorsal  or  lumbar  region, 
shooting  into  the  hips  and  thighs,  persistent  and  increased  by  pres- 
sure ;  tenderness  on  motion  ;  tingling  sensations  in  the  limbs  and  feet, 
and  sometimes  in  the  hands  and  arms ;  a  feeling  of  constriction 
about  the  abdomen  is  often  present,  with  rigidity  of  the  abdominal 
29 


450  PRACTICE    OF    MEOICINE. 

muscles.  Increased  reflexes,  with  disorders  of  motility,  and  when  the 
patient  is  in  the  recumbent  ^o%\\\ox\,  jerking  of  tite  livd>s.  On  attempt- 
ing to  walk,  it  is  accomplished  with  difficulty,  from  an  incomplete  loss 
of  power. 

If  the  upper  part  of  the  cord  be  affected,  dyspnaa  and  palpitation 
occur. 

There  often  occur  painful  priapism  and  frequent  nocturnal  emis- 
sions. 

The  above  symptoms  may  be  followed  by  a  more  or  less  pro- 
nounced temporary  depression,  the  sensation  diminished,  and  the 
lower  limbs  benumbed  and  heavy,  the  movements  weak. 

The  electro-contractility  is  preserved,  and  in  many  cases  even  in- 
creased or  exaggerated. 

Duration.  From  a  few  hours  to  several  days;  if  longer,  myelitis 
may  result. 

Diagnosis.  AncBmia  causes  more  or  less  spinal  irritability  and 
tenderness  ;  but  the  history,  pallor,  and  general  weakness,  unasso- 
ciated  with  defects  of  motility  or  sensibility,  will  prevent  error. 

Spinal  meningeal  hetnorrhage  is  more  sudden  in  its  onset,  its  vio- 
lence, and  its  range  of  symptoms. 

Myelitis  and  spinal  meningitis  have  symptoms  in  common  with 
spinal  congestion,  which  will  be  pointed  out  when  discussing  those 
conditions. 

Prognosis.     Favorable,  recovery  occurring  in  three  or  four  days. 

If  the  symptoms  show  a  tendency  to  linger,  myelitis,  more  or  less 
pronounced,  will  ensue. 

Treatment.  Rest,  but  avoid  lying  on  the  back;  cups  or  leeches 
along  the  spine,  followed  either  by  the  iced  or  the  hot  douche,  or  hot 
sponges,  with  active  purgation,  to  diminish  the  blood  pressure. 

If  the  result  of  suddenly  arrested  Y>tr%^\r2i\.\on , pilocarpus  and  a  hot- 
air  bath.  If  following  suddenly  arrested  menses,  aconitum.  If 
associated  with  an  active  chcu\a.i\oT\,potassiidromidufn,or  extracttttn 
gelsemiifluidiim,  r(\y  (0.3  Cc),  every  four  hours,  or  extractum  ergotce 
fluidum,  foss-j  (2-4  Cc),  repeated  p.  r.  n. ;  and  in  all  cases  active 
purgation. 

For  the  passive  form,  treating  the  cause,  ergota,  digitalis,  tonics, 
and  purgatives. 


DISEASES   OF  THE  SPINAL  CORD.  451 


PACHYMENINGITIS  SPINALIS. 

Synonyms.  Pachymeningitis  spinalis  interna ;  hypertrophic 
pachymeningitis ;  pseudo-membranous  pachymeningitis. 

Definition.  An  inflammation  of  the  inner  surface  of  the  spinal 
dura  mater ;  characterized  by  violent  pains  in  the  head,  neck,  shoul- 
ders, and  arms,  followed  by  contractures  and  paralyses  of  the  upper 
extremities. 

Causes.  Exposure  to  cold  and  damp  ;  alcoholism  ;  syphilis ;  gout ; 
injuries. 

Pathological  Anatomy.  Hypertrophic  pachymeningitis  is 
characterized  by  an  exudation  upon  the  inner  surface  of  the  dura 
mater,  which  gradually  solidifies  into  a  layer  of  compact  connective 
tissue,  this  presses  upon  the  spinal  cord  and  nerves,  producing  a 
myelitis  and  atrophic  neuritis,  resulting  in  muscular  atrophy. 

The  most  frequent  seat  of  this  form  of  the  affection  is  the  cervical 
region,  as  first  demonstrated  by  Charcot,  whence  the  term  cervical 
hypertrophic  pachymeningitis. 

In  the  pseudo-membranous  form  a  membranous  ex^udation  also 
occurs,  in  which  large  numbers  of  blood-vessels  develop  and  rupture, 
the  hemorrhagic  extravasation  forming  a  cyst — hasmatoma — which 
causes  pressure  on  the  cord  and  nerves. 

Symptoms.  The  onset  is  slow  and  gradual,  with  irregular  chills 
arvd.  feverishness ,  violent  pains,  and  stiffness  in  the  head,  neck,  shoul- 
ders, and  arms,  continuous,  but  subject  to  exacerbations,  and  associ- 
ated with  a.  painful  constriction  of  the  upper  thorax.  Numbness  and 
prickling  occur  in  the  arms,  more  marked  in  one  than  the  other. 
Rarely  nausea  and  vomiting  occur.  These  symptoms  may  continue 
off  and  on  for  several  months,  the  muscles  of  the  painful  parts 
atrophying,  followed  by  spasmodic  contraction,  particularly  of  the 
hands  and  wrists,  followed  later  by  paralysis. 

The  paralytic  stage  develops  gradually,  with  weakness  in  the  arms, 
associated  with  contractures  and  rigidity.  The  pain  continues  with 
anaesthesia,  hypersesthesia,  and  trophic  changes.  Later,  paraplegia 
with  rigidity,  exaggerated  reflexes,  and  spinal  epilepsy  develop. 

The  development  of  tuberculosis  and  nephritis  during  the  progress 
of  chronic  cerebral  and  spinal  diseases,  which  are  the  immediate 
cause  of  death,  is  a  clinical  observation. 


452  PRACTICE    OF    MEDICINE. 

The  tlectro-contractility  is  lost. 

Prognosis.  If  early  recognized  and  promptly  treated,  the  hyper- 
trophic form  may  be  improved.  Generally,  however,  the  prognosis 
is  unfavorable. 

Treatment.  Rest ;  nutritious  diet ;  oleum  viorrhua,  and  the 
hypophosphites ;  large  doses  oi  poiassii  iodidum,  and  repeated  but 
systematic  counter-irritation. 

Symptomatic  remedies  for  the  pain  and  spasms  are  indicated. 


SPINAL  MENINGITIS. 

Synonym.     Leptomeningitis  spinalis. 

Definition.  Inflammation  of  the  arachnoid  and  pia  mater  mem- 
branes of  the  spinal  cord,  either  acute,  subacute,  or  chronic ;  charac- 
terized by  pain  in  the  back,  rigidity  of  the  muscles,  disorders  of  motility 
and  sensibility.     It  may  be  acute  or  chronic. 

Causes.  The  disease  is  rare  and  is  always  due  to  an  infection 
from  tubercle,  syphilis,  typhoid  fever,  or  septicaemia,  or  the  result  of 
a  traumatism. 

Pathological  Anatomy.  Acute.  Hyperasmia  of  the  mem- 
branes, with  swelling  of  the  tissues,  the  result  of  serous  infiltration, 
followed  by  purulent  and  fibrinous  exudations.  The  roots  of  the 
spinal  nerves  are  covered  with  exudation,  and  are  swollen  and  soft. 
The  cord  proper  is  more  or  less  congested  and  oedematous. 

Chronic.  Adhesion  of  the  membranes,  with  more  or  less  accu- 
mulation of  fluid,  resulting  in  atrophic  degeneration  of  the  cord  from 
pressure. 

If  the  disease  is  secondary  to  tubercle,  these  granulations  are  seen 
distributed  over  the  pia,  arachnoid,  and  inner  surface  of  the  dura. 

Symptoms.  There  are  two  stages:  the  first,  the  stage  of  irrita- 
tion ;  the  second,  the  stage  of  paralysis  of  motion  and  sensation,  with 
atrophy.  Although  an  inflammatory  affection,  yet  its  onset  is  usually 
subacute,  the  febrile  reaction  being  moderate,  with  intense  boring 
pain  in  the  back,  aggravated  by  motion,  rigidity  of  the  spine,  and  a 
sense  oi  constriction  around  the  body, — "  the  girdle."  Spasmodic  con- 
tractions of  the  muscles  enervated  by  the  nerves  originating  at  the 
seat  of  the  lesion,  with  inability  to  straighten  the  limbs.  If  the  lower 
part  of  the  spinal  membranes  is  the  seat,  there  occur  retention  of 


DISEASES   OF   THE   SPINAL   CORD.  453 

urine  and  constipation  ;  if  upper  part,  dysphagia,  dyspncea,  a.rvdfeeb/e 
heart.  The  muscular  contractions  are  excited  or  increased  by  motion, 
but  uninfluenced  by  pressure.  Reflex  77ioveinents  are  not  abolished. 
The  rigidity  and  spasmodic  contraction  of  the  muscles  are  followed 
hy paralysis ,  more  or  less  complete,  death  following  from  paralysis  of 
the  muscles  of  respiration. 

If  the  inflammation  extend  to  the  medulla,  the  above  symptoms  are 
associated  with  disorders  of  speech,  voiniting,  and  delirium. 

Electro-contractility  lessened  or  absent,  both  as  to  motility  and 
sensibility  in  the  affected  parts. 

Chronic  form  succeeds  to  the  acute  or  originates  spontaneously, 
and  presents  the  same  form  and  order  of  symptoms — excitation  or 
irritation,  and  depression  or  paralysis. 

Diagnosis.  The  points  of  importance  are  :  deep,  boring  pain  in 
the  back,  aggravated  by  motion  but  not  by  pressure,  with  spasmodic 
contraction  of  the  muscles,  followed  by  paralysis. 

Myelitis  slight,  or  absence  of  pain,  with  earlier  and  more  complete 
paralysis. 

Tetanus  may  be  confounded  with  spinal  meningitis.  The  points  of 
distinction  are :  in  the  former  occur  early  trismus  with  rhythmical 
spasms  excited  by  irritation  of  the  skin,  whereas  irritation  of  the  skin 
does  not  in  spinal  meningitis  produce  muscular  contractions,  but 
movement  of  the  limbs  does  do  so  ;  progressively  increasing,  and  not 
associated  with  fever  ;  usually  a  clear  history  of  an  injury. 

Prognosis.  Generally  unfavorable.  Death  is  either  sudden,  from 
paralysis  of  respiration  and  of  the  heart,  or  gradually,  the  result  of 
exhaustion. 

Critical  discharges,  such  as  profuse  perspiration,  urinary  flow,  or 
epistaxis  occur,  and  are  followed  by  rapid  recovery.  Cases  recover- 
ing may  have  more  or  less  pronounced  partial  or  complete  paralysis. 

Treatment.  Rest  in  bed,  upon  the  side  or  face.  Cups  or  leeches 
along  the  spine,  followed  by  ice,  the  hot  douche^  hot  sponges,  or 
mustard.     Active  purgation. 

If  the  result  of  syphilis,  full  doses  of  potassii  iodidum,  gr.  x-xl 
(0.6-2.6  Gm.),  combined  wiih  hydrargyri  chloriditm  corrosivtmt, 
gr-  -sVtV  (0.0025-0.005  Gm.). 

For  the  paralytic  stage,  guinincB  sulphas,  gr.  iij  (0.2  Gm.),  with 
extractuin  belladonnce  alcoholic,  gr.  }(  (0.016  Gm.),  three  times  a  day, 
is  sometimes  useful. 


454  PRACTICE    OF   MEDICINE. 

For  paralysis,  the  j^^ahmtiic  current  to  the  spine  and  nerve  trunks, 
and  \.\\e  faraiiic  current  to  the  affected  muscles,  with  the  deep  injec- 
tion of  strychnina  and  the  use  of  massage. 


ACUTE  MYELITIS. 

Synonyms.  Acute  or  general  diffuse  myelitis  ;  transverse  mye- 
litis ;  softening  of  the  cord. 

Definition.  An  inflammation  affecting  the  substance  of  the 
spinal  cord,  which  may  be  limited  to  the  gray  or  white  matter,  and 
involve  the  whole  or  isolated  portions  of  the  cord.'  When  the  gray 
matter  alone  is  inflamed,  it  is  termed  central  myelitis  ;  when  the 
white  matter  and  the  meninges,  it  is  termed  cortical  myelitis  ;  it  may 
be  ascending,  descending,  or  transverse  in  its  extension.  The  dis- 
ease is  characterized  by  more  or  less  sudden  and  complete  loss  of 
motion  and  sensation. 

Causes.  Following  spinal  meningitis;  exposure  to  cold  and 
damp  or  wet  weather  ;  injuries  to  the  vertebra;  ;  prolonged  func- 
tional activity  of  the  cord;  typhus  fever;  rheumatism;  syphilis ; 
puerperal  fever,  or,  during  the  course  of  the  exanthemata,  arsenical, 
lead,  or  mercurial  poisoning. 

Pathological  Anatomy.  Intense  hyperaemia  of  the  substance 
of  the  cord,  with  extravasations,  giving  the  tissues  a  reddish-brown 
or  chocolate  tint,  and  also  serous  transudations,  resulting  in  soften- 
ing of  the  structure  of  the  cord,  the  color  changing  to  yellow  and 
white,  the  nerve  elements  undergoing  fatty  degeneration,  presenting 
the  appearance  and  consistency  of  cream.  The  membranes  also 
undergo  more  or  less  change. 

Symptoms.  The  severity  of  the  symptoms  depend  upon  the 
extent  and  location  of  the  inflammation. 

The  onset  is  usually  sudden,  with  a  chill,  fever,  103°  F.,  frequent 
pulse,  with  alterations  in  sensibility  and  motility — to  wit :  pain  in  the 
back,  aggravated  by  touch  and  by  heat  and  cold,  with  sensations  of 
formication  ("  pins  and  needles"),  the  limb  feeling  as  if  asleep,  or 
else  complete  ancesthesia,  associated  with  severe  neuralgic  pains. 

The  distinction  between  ancssthesia,  insensibility  to  touch,  and 
analgesia,  insensibility  to  pain,  must  be  clearly  determined. 

A  sensation  o{  constriction  around  the  body  and  limbs,  as  if  encircled 
by  a  tight  cord,  "  the  girdle  pains,"  is  a  characteristic  symptom,  fol- 


DISEASES   OF  THE  SPINAL   CORD.  455 

lowed  by  rapidly  developing  paraplegia,  complete  in  a  few  hours, 
with  involuntary  discharges.  The  reflex  fiaictions  are.  usually  abol- 
ished, as  seen  by  attempting  to  cause  movement  of  the  limbs  by  tick- 
ling the  feet  or  by  striking  the  patella  tendon  ;  rarely  are  they  dimin- 
ished, very  rarely  exaggerated.  The  temperature  of  the  affected 
limbs  is  lowered  three  or  four  degrees. 

Sloughs  and  bed-sores  and  muscular  atrophy  result  if  the  anterior 
cornua — the  trophic  centres — are  affected. 

The  symptoms  of  loss  of  motion  ajid  sensibility,  with  rectal  and 
vesical  paralysis,  are  associated  with  more  or  less  pronounced  vomit- 
ing, hepatic  disorders,  irregularity  of  the  heart,  dyspnoea,  dysphagia, 
apnoea,  and  painful  priapisms.  The  urine  is  markedly  alkaline  in 
reaction,  finally  developing  cystitis. 

Among  the  late  manifestations  are  shooting"  pains  and  spasmodic 
twitchings  or  contractions  of  one  or  all  of  the  muscles  of  the  paralyzed 
parts. 

The  electro-contractility  is  abolished  in  the  paralyzed  parts. 

Diagnosis.  Acicte  spinal  meningitis  is  distinguished  from  acute 
myelitis  by  severe  pains,  increased  by  pressure,  with  muscular  con- 
tractions increased  by  motion,  followed  by  paralysis  much  less  pro- 
found than  the  paraplegia  of  myelitis ;  in  spinal  meningitis  there  exists 
cutaneous  and  muscular  hypersesthesia,  which  are  absent  in  myelitis. 

Congestion  of  the  spinal  cordis  characterized  by  the  mild  character 
and  short  duration  of  all  the  symptoms. 

Hemorrhage  in  the  spinal  canal  is  abrupt  with  irritative  symp- 
toms, slight  paralysis,  preserved  reflexes,  and  electro-contractility. 

The  principal  diagnostic  points  of  acute  myelitis  are  the  "  girdle  " 
around  the  limbs  or  body,  rapid  and  complete  paraplegia,  loss  of 
sensation,  lowered  temperature  in  the  affected  parts,  early  and  per- 
sistent sloughing  (bed-sores),  and  alkaline  urine  or  cystitis. 

Hysterical  paraplegia  shows  no  trophic  changes,  no  altered  reflexes, 
slight  atrophy,  irregular  anaesthesia,  contractures  with  impaired  sensa- 
tion of  the  contracted  limb,  and  the  presence  of  the  stigmata  of  hysteria. 

LithcEinic  parcesthesia,  tingling  and  numbness  of  fingers  and  toes, 
might  lead  to  error  if  the  cerebral  symptoms  of  lithaemia  are  overlooked. 

The  diagnosis  of  the  location  of  the  lesio7i  is  made  by  a  study  of  the 
height  of  the  ansesthesia,  the  skin  reflexes,  and  the  distribution  and 
extent  of  the  paralysis,  which  are  shown  in  the  following  table  from 
Dana,  based  on  that  originally  devised  by  Starr  and  modified  by 
Mills  and  Dana. 


456 


PRACTICE    OF    MEDICINE. 


LOCALIZATION  OF   THE  FUNCTIONS  OF   THE  SEGMENTS  OF 
THE  SPINAL  CORD. 


Segment. 

Muscles. 

Reflex  and  Centres. 

Sensation. 

First  cervi- 

Rectus laterales. 

cal. 

Rectus  capitis. 
Aiiticus  and  posticus. 
Sterno  liyoid. 
Sterno-thyroid. 

fjecond     and 

Sterno-mastoid. 

Hypochondi  turn      (?). 

Back  of  head  to  vertex 

third  cervi- 

Trapezius. 

Sudden    inspiration 

and  neck.      (Occipi- 

cal. 

Scaleni  and  neck. 

produced  by  sudden 

talis    major,    occipi- 

Omo hyoid. 

pressure  beneath  the 
lower  border  of  ribs. 

talis    minor,  auricu- 

Diaphragm. 

laris  magnus,  super- 

ficialis  colli,  and  su- 

praclavicular.) 

Fourth    cer- 

Diaphragm. 

Pupillary  (fourth  cer- 

Neck. 

vical. 

Deltoid. 

vical  to  second  dor- 

Shoulder, anterior  sur- 

Biceps. 

sal).      Dilatation    of 

face. 

Coraco-brachialis. 

the   pupil  produced 

Outer  arm.    (Supracla- 

Supinator longus. 

by  irritation  of  neck. 

vicular,    circumflex. 

Rhomboid. 

external  musculo-cu- 

Supra-    and   infra-spi- 

taneous,  cutaneous.) 

natus. 

Fifth     cervi- 

Deltoid. 

Scapular  (fifth  cervi- 

Back of  shoulder  and 

cal. 

Biceps. 

cal   to   first  dorsal). 

arm. 

Coraco-brachialis. 

Irritation     of    skin 

Outer  side  of  arm  and 

Brachialis  anticus. 

over     the     scapula 

forearm  to  the  wrist. 

Supinator  longus. 

produces      contrac- 

(Supraclavicular, cir- 

Supinator brevis. 

tion      of     scapular 

cumflex,  external  cu- 

Deep muscles  of  shoul- 

muscles. 

taneous,  internal  cu- 

der-blade. 

Supinator    longus. 

taneous,       posterior 

Rhomboid. 

Tapping  the  tendon 

spinal  branches.) 

Teres  minor. 

of  the  supinator  lon- 

Pectoralis   (clavicular 

gus  produces  flexion 

part). 

of  forearm. 

Serratus  magnus. 

Sixth    cervi- 

Deltoid. 

Triceps  (fifth  to  sixth 

Outer  side    and    front 

cal. 

Biceps. 

cervical).     Tapping 

of  forearm. 

Brachialis  anticus. 

elbow    tendon    pro- 

Back of  hand,  radial 

Subscapular. 

duces  extension    of 

distribution. 

Pectoralis    (clavicular 

forearm. 

(Chiefly      external 

part). 

Posterior  turist  (sixth 

cutaneous,     internal 

Serratus  magnus. 

to  eighth  cervical). 

cutaneous,  radial.) 

Triceps. 

Tapping  tendons 

Pronators. 

causes  extension  of 

Rhomboid. 

hand. 

Latissimusdorsi. 

Seventh  cer- 

Triceps (long  head). 

Anterior  wrist    (sev- 

Radial distribution  in 

vical. 

Extensors     of     wrist 

enth   to  eighth  cer- 

the hand. 

and  fingers. 

vical).      Tapping 

Median  distribution  in 

Pronators  of  wrist. 

anterior    tendons 

the  palm,  thumb,  in- 

Flexors of  wrist. 

causes  flexion    of 

dex,    and    one-half 

Subscapular. 

wrist. 

middle  finger. 

Pectoralis  (costal  part). 

Palmar  (seventh  cer- 

(External   cutane- 

Serratus magnus. 

vical  to  first  dorsal). 

ous,     internal    cuta- 

Latissimus dorsi. 

Stroking     palm 

neous,    radial,     me- 

Teres major. 

causes  closure  of 

dian,  posterior  spinal 

fingers. 

branches.) 

Eighth  cervi- 
cal. 

Triceps  (long  head). 
Flexors  of  wrist  and 

Ulnar    area    of    hand, 

back  and  palm,  inner 

fingers. 

border    of   forearm. 

Intrinsic    hand    mus- 

(Internal cutaneous, 

cles. 

ulnar.) 

DISEASES   OF  THE   SPINAL  CORD. 


457 


LOCALIZATION  OF  THE  FUNCTIONS  OF   THE   SEGMENTS  OF 
THE  SPINAL  COKD.—Contimted. 


Segment. 


First  dorsal. 


Second  dor- 
sal. 

Second  to 
twelfth  dor- 
sal. 


First  lumbar. 


Second  lum- 
bar. 


Third 
bar. 


Fourth   lum- 
bar. 


Fifth  lumbar. 


First  and 
second  sa- 
cral. 


Third,  fourth, 
and  fifth  sa- 
cral. 


Muscles. 


Extensors  of  thumb. 

Intrinsic  hand  mus- 
cles. 

Thenar  and  hypothe- 
nar  muscles. 


Muscles  of  back   and 

abdomen. 
Erectores  spinae. 


None. 


Vastus  internus. 


Sartorius ;    adductors 

of  thigh. 
Flexors  of  thigh. 
Extensors  of  knee. 
Abductors  of  thigh. 


Outward  rotators. 
Flexors  of  knee. 
Flexors  of  ankle. 
Peronei. 
Extensors  of  toes. 


Calf  muscles. 

Glutei. 

Peronei. 

Extensors  of  ankle. 

Small  muscles  of  foot. 

Perineal. 

Muscles  of  bladder, 
rectum,  and  exter- 
nal genitals. 


Reflex  and  Centres. 


Epigastric  (fourth  to 
seventh  dorsal). 
Tickling  mammar\- 
region  causes  re- 
traction of  the  epi- 
gastrium. 

Abdominal{%e.\&\i\.\\  to 
eleventh  dorsal). 

Stroking  side  of  abdo- 
men causes  retrac- 
tion of  belly. 

Vasomotor  centres. 
Second  dorsal  to 
second  lumbar. 

Cremasteiic  (first  to 
third  lumbar). 
Stroking  inner  thigh 
causes  retraction  of 
scrotum. 

Patellar.  Striking 
patellar  tendon 
causes  extension  of 
leg. 


Gluteal  (fourth  to  fifth 
lumbar).  Stroking 
buttock  causes  dimp- 
ling in  fold  of  buttock. 
Achilles  tendon.  Over- 
extension causes 
rapid  flexion  of 
ankle,  called  ankle 
clonus. 


Plantar  (fifth  lumbar 
to  second  sacral). 
Tickling  sole  of  foot 
causes  flexion  oftoes 
and  retraction  of  leg. 

Genital  centre. 

Vesical  centre. 

Anal  centre. 


Sensation. 


Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla. 

(Chiefly  intern  al 
cutaneous  and  nerve 
of  Wrisberg  or  lesser 
internal  cutaneous.) 

Inner  side  of  arm  near 
and  in  axilla.  (la- 
tercosto-humeral.) 

Skin  of  chest  and  ab- 
domen, in  bands  run- 
ning around  and 
downward,  corre- 
sponding to  spinal 
nerves. 

Upper  gluteal  region. 
(Ii]tercostals  and 
dorsal  posterior 
nerves.) 


Skin  over  groin  and 
front  of  scrotum, 
(llio-hy  pogastric, 
ilio-inguinal.) 

Outer  side  and  upper 
front  of  thigh.  Lum- 
barregion.  (Genito- 
crural ,  external  cuta- 
neous.) 

Front  and  outer  side 
of  thigh.  Inner  side 
of  leg  and  foot. 

Inner  side  of  thigh,  leg, 
and  foot.  (Internal 
cutaneous,  long  sa- 
phenous, obturator.) 

Back  of  thigh  and 
outer  side  of  leg  and 
ankle;  sole;  dorsum 
of  foot.  (External 
popliteal,  external 
saphenous,  musculo- 
cutaneous, plantar.) 

Back  of  buttock  and 
thigh  ;  side  of  leg  and 
ankle  ;  sole  ;  dorsum 
of  foot. 

Circumanal  region, 
anus,  rectum,  penis, 
urethra,  vagina, 
perineum. 

(Small  sciatic, 
pudic,  inferior  hem- 
orrhoidal, inferior 
pudendal.) 


458  PRACTICE   OF    MEDICINE. 

Prognosis.  Depends  upon  the  location  of  the  lesion  and  com- 
pleteness of  the  symptoms. 

If  the  paralysis  is  of  the  ascending  variety,  death  occurs  within  a 
few  days,  from  paralysis  of  the  muscles  of  respiration. 

If  the  trophic  centres  are  affected,  there  occur  bed-sores,  intense 
pyelo  nephritis  and  cystitis  and  changes  in  the  joints  ;  death  from 
exhaustion  in  several  weeks. 

Central  myelitis,  or  inflammation  of  \}[\& gray  matter,  is  rapid  in  its 
progress,  death  occurring  in  a  week  or  two. 

The  morbid  process  may  be  arrested  and  the  general  health 
restored,  but  some  spinal  symptoms  will  persist. 

Treatment.  Absolute  rest  is  essential  to  even  secure  a  palliation 
of  the  symptoms. 

Locally,  considerable  relief  follows  the  use  of  hot-water  bags  or 
sponges  dipped  in  //t?/ water  and  applied  along  the  spine  every  few 
hours. 

The  remedies  most  strongly  recommended  are :  digitalis,  strychnince 
sulphas,  ergota,  belladonna,  bromides,  cimicifuga,  and  qitinince 
sulphas,  although  I  have  never  observed  a  cure  with  any  plan  of  med- 
ication after  the  disease  was  fairly  established.  Cases  due  to  syphilis 
are  benefited  by  large  doses  oi potassii  iodidum.  Gray  reports  having 
administered  700  grains  daily  before  improvement  began. 


INFANTILE  SPINAL  PARALYSIS. 

Synonyms.  Myelitis  of  the  anterior  horns;  poliomyelitis  ante- 
rior acuta  ;  essential  paralysis  of  children  ;  atrophic  paralysis  of  chil- 
dren. 

Definition.  A  rapidly  developed  inflammation  of  the  anterior 
horns  of  the  gray  matter  of  the  cord,  occurring  suddenly  in  children, 
at  times  in  adults, — acute  spinal  paralysis  of  adults, — characterized 
by  mild  fever,  muscular  tremors  and  twitchings,  and  paralysis  of 
groups  of  muscles,  followed  by  more  or  less  atrophy. 

Causes.  Essentially  a  disease  of  early  life — the  second  month  to 
the  third  or  fourth  year.  The  fact  of  its  having  occurred  in  adults 
must  be  borne  in  mind.  Cold  and  damp ;  dentition  (?) ;  injuries  to 
the  spine  ;  developed  during  convalescence  from  the  acute  exanthe- 
mata. 


DISEASES   OF  THE  SPINAL  CORD.  459 

Pathological  Anatomy.  The  early  changes  are :  Medullary 
hyperaemia,  vascular  exudation  and  inflammatory  softening,  although 
the  naked  eye  may  not  recognize  any  changes.  Microscopical  exam- 
ination reveals  inflammatory  softening  of  the  anterior  horns  of  the 
gray  matter.  Among  other  constant  lesions  are  atrophic  degenera- 
tion of  the  multipolar  ganglion  cells  and  of  the  anterior  nerve  roots. 

The  changes  noted  as  occurring  in  the  cord  are  usually  limited  to 
the  dorso-lumbar  and  cervical  enlargements. 

As  a  direct  result  of  the  changes  in  the  trophic  centres  and  the  nerve 
degeneration  of  the  muscular  fibres  supplied,  there  ensue  changes  in 
the  bones  and  joints,  leading  to  great  deformities. 

Symptoms.  The  onset  of  the  aflection  varies  ;  it  may  be  acute, 
subacute,  or  chronic  ;  it  is  usually  sudden,  with  an  attack  of  mild 
fever  of  a  remittent  type,  of  a  few  days'  duration,  on  recovery  from 
which  it  is  noticed  that  the  child  is  paralyzed.  Rarely,  the  paralysis 
may  be  preceded  by  convulsions. 

The  paralysis  may  affect  both  arms  and  both  legs,  the  legs  alone, 
or  only  one  of  the  four  extremities ;  it  may,  but  very  rarely,  be  a 
hemiplegia.  As  a  rule,  however,  the  leg  suffers  more  frequently  than 
the  arm :  in  paralysis  of  the  leg  the  muscles  below  the  knee  suffer 
more  severely  than  those  above.  The  bladder  and  rectum  are  not 
affected,  or  if  so,  only  temporarily,  nor  can  anaesthesia  or  numbness 
be  detected.  The  temperature  of  the  paralyzed  limb  is  low  and  the 
appearance  cyanosed.  After  a  few  days  there  is  a  slight  improve- 
ment in  the  paralyzed  parts,  although  the  muscles  show  a  rapid 
wasting,  which  is  progressive  until  all  muscular  tissue  is  gone. 

The  reflex  movements  are  impaired  or  abolished. 

The  electro-contractility  by  the  faradic  current  is  abolished  in  the 
paralyzed  parts. 

With  the  galvanic  or  constant  current  the  "  reactions  of  degenera- 
tion "  are  developed.  To  fully  understand  the  meaning  of  this  term 
a  knowledge  of  the  normal  electrical  reactions  is  necessary. 

The  normal  formula  for  the  production  of  muscular  contraction  in 
the  physiological  state  are  as  follows,  the  strength  of  the  current  being 
barely  capable  of  causing  fair  contractions  : 

First.  The  most  effective  contractions  are  produced  by  the  cathode 
{negative)  pole  on  closing  the  circuit  (C.  C). 

Second.  The  second  most  effective  are  produced  by  the  anode  {pos- 
itive) pole  on  closing  the  circuit  (A.  C). 


460  PRACTICE    OF    MEDICINE. 

Third.  The  next  most  effective  is  by  the  anode  pole  on  opening  the 
circuit  (A.O.). 

Fourth.  Cathode  pole  contractions  on  opening  circuit  are  rarely 
seen  in  the  physiological  state  (C.  O.). 

The  "  reactions  of  degeneration  "  are  shown  by  any  reversal  of  the 
regular  formula: — to  wit :  if  the  anodal  closure  (A.  C.)  shows  stronger 
contractions  than  lathoda/ closure  (C.  C.) ;  still  greater  degeneration  is 
shown  \{ anodal openingf^K.  O.)  contractions  are  stronger  than  either  of 
the  above  ;  and  most  complete  degeneration  is  shown  by  the  complete 
reversal  of  the  normal  formulae  as  shown  by  distinct  ^aM^r/a/ opening 
(C.  O.)  contractions. 

Sequelae.  Amongst  the  deformities  resulting  from  the  paralysis 
are  the  different  forms  of  talipes. 

Talipes  equinus,  the  result  of  paralysis  of  the  antero-external  mus- 
cular group  of  the  leg. 

Equino-varus,  the  result  of  paralysis  of  the  antero-external  mus- 
cular group  of  the  leg,  together  with  the  adductors  of  the  foot. 

Talipes  calcaneus,  the  result  of  paralysis  of  the  muscles  of  the  calf 
of  the  leg. 

Talipes  cavus, — "  pes  cavus," — characterized  by  the  hollowing  of 
the  sole  of  the  foot,  with  prominence  of  the  instep,  the  result  of 
paralysis  of  the  calf  muscles  with  contraction  of  the  long  flexor  of 
the  toe  or  the  long  peroneus — the  foot  flexors. 

Diagnosis.  The  recognition  of  acute  poliomyelitis  is  not  always 
possible  at  the  onset  or  during  its  early  days,  as  localized  paralyses 
are  difficult  of  detection  in  children,  but  immobility  of  one  leg  or  arm 
in  children  with  febrile  symptoms  or  following  convulsions  is  always 
an  indication  of  poliomyelitis.  After  the  initial  stage  has  passed,  the 
presence  of  paralysis,  wasting,  presence  of  R.  D.  (reactions  of  degen- 
eration), loss  of  reflexes,  and  the  absence  of  anaesthesia,  render  the 
diagnosis  very  easy. 

Hemiplegia  from  acute  cerebral  affections  in  children  can  be  dis- 
tinguished from  infantile  paralysis  by  the  disorders  of  intelligence 
and  the  special  senses,  and  the  perseverance  of  the  normal  electro- 
contractility. 

Paralysis  of  myelitis  occurs  in  older  persons,  and  is  associated  with 
disturbances  of  the  genito-urinary  organs  and  bed-sores. 

Pseudo-muscular  hypertrophy,  with  paralysis,  begins  gradually, 
becoming  progressively  worse  with  increase  in  the  size  of  the  limbs. 


DISEASES   OF  THE  SPINAL  CORD.  461 

Prognosis.  More  or  less  paralysis,  with  muscular  wasting,  always 
results,  although  there  is  no  doubt  that  the  extent  can  be  greatly 
lessened  by  early  recognition  and  treatment. 

Treatment.  The  diagnosis  during  the  initial  fever  is  impossible, 
so  that  its  treatment  is  symptomatic.  On  the  appearance  of  the 
paralysis,  complete  rest,  hot  spinal  douche,  mild  galvanism,  and 
internally,  quitiina,  belladonna,  ergota,  d.w.A. potassii  iodidinn. 

With  the  improvement  that  follows  the  above  measure,  use  inter- 
nally ti7icinra  nucis  vomicce,  Tr\j-iij  (0.06-0.2  Gm.),  three  times  daily, 
or  hypodermic  injections  of  strychnine  sulphas,  gr.  t\-ioq  (0.004- 
0.00065  Gm.),  according  to  age,  twice  a  week,  d^ndi  faradism  to  the 
paralyzed  muscles. 


CHRONIC  PROGRESSIVE  BULBAR  PARALYSIS. 

Synonyms.     Glosso-labio-laryngeal  paralysis  ;  bulbar  paralysis. 

Definition.  A  chronic  degenerative  affection  of  certain  nuclei 
of  the  medulla  oblongata ;  characterized  by  a  slowly  progressive 
bilateral  paralysis  of  the  tongue,  lips,  palate,  pharynx,  and  larynx, 
with  atrophy  of  the  tongue  and  lips. 

Causes.  Obscure.  Rare  before  the  fortieth  year.  Among  many 
others  may  be  named  cold,  rheumatism,  gout,  syphilis,  and  injuries 
about  the  neck. 

Pathological  Anatomy.  "  Degenerative  atrophy  of  the  gray 
nuclei  in  the  floor  of  the  fourth  ventricle  ;  with  atrophy  and  gray  dis- 
coloration of  the  nerve  roots  from  the  medulla,  especially  of  the  facial 
and  hypoglossal  nerves."  "  Atrophy  and  disappearance  of  the  motor 
ganglion  cells  are  always  to  be  noted.     It  may  be  the  sole  lesion." 

"  The  nerves  going  to  the  muscles  exhibit  sclerosis  of  the  neuri- 
lemma, and  the  degenerative  atrophy  is  found  in  the  nerve  roots 
coming  from  the  bulb." 

Symptoms.  The  disease  begins  insidiously.  There  is  first 
noticed  some  difficulty  in  articulation,  from  want  of  precision  in 
movements  of  the  tongue;  particularly  in  the  use  of  the  lingual  con- 
sonants, /,  n,  r,  and  /,  which  increases  until  that  organ  is  completely 
paralyzed.  The /ara/j/jz^  gradually  invades  tht  soft  palate  7\.r\d.  pharyn- 
geal muscles,  causing  difficulty  in  deglutition,  of  the  orbicularis  oris 
preventing  closure  of  the  lips,  of  the  laryngeal  muscles,  interfering 


462  PRACTICE    OF    MEDICINE. 

with  arlicHlaiion.  With  the  increasing  loss  of  power  in  the  tongue 
and  lips  is  also  a  gradual  atrophy  of  these  nuisc  les  ;  tlie  atrophy 
usually  antedates  the  paralysis.  When  the  disease  is  fully  devel- 
oped, the  condition  of  the  patient  is  most  pitiable,  indeed  ;  articulation 
is  impaired  or  impossible,  deglutition  interfered  with,  the  lips  remain- 
ing apart  allowing  the  saliva  to  dribble  from  the  mouth  and  liquids 
to  return  through  the  nose  with  attempts  at  swallowing.  As  the 
malady  progresses,  the  pneumogastric  nucleus  becomes  involved, 
resulting  in  loss  of  voice,  difficulty  of  respiration,  and  cardiac  irregu- 
larity. The  general  health  gradually  suffers  from  insufficient  nutri- 
tion and  imperfect  respiration,  although  the  inimi  is  clear  until  the 
end.    The  "  reactions  of  degeneration  "  are  present. 

Besides  the  chronic  bulbar  paralysis,  there  are  two  acute  forms 
with  the  same  symptoms  as  the  chronic  cases,  only  they  develop 
suddenly,  one,  the  result  of  hemorrhage  into  the  nieduHa,  which  at  the 
onset  has  vertigo,  vomiting,  loss  of  power  in  the  limbs,  and  slight 
sensory  disturbances,  all  of  which  disappear,  leaving  the  glosso- 
labio-laryngeal  paralysis ;  the  second  form  comes  suddenly,  with 
fever,  vomiting,  and  loss  of  power  in  the  limbs,  soon  disappearing, 
leaving  the  characteristic  bulbar  symptoms;  this  variety  is  inflam- 
matory and  closely  allied  to  acute  poliomyelitis. 

Diagnosis.     It  can  hardly  be  confounded  with  any  other  malady. 

Prognosis.  Unfavorable.  The  duration  is  from  one  to  five 
years. 

Treatment.  Entirely  symptomatic.  "  Galvanism  is  the  most 
promising  remedy.  Stabile  applications,  the  electrodes  on  the  mas- 
toid processes  and  in  the  opposite  direction,  galvanization  of  the 
sympathetic,  and  applications  to  the  lips,  tongue,  and  fauces,  should 
be  persistently  used"  (Bartholow). 


PROGRESSIVE  MUSCULAR  ATROPHY. 

Synonyms.  Wasting  palsy  ;  chronic  spinal  muscular  atrophy; 
chronic  jjoliomyelitis  ;  amyotrophic  lateral  sclerosis. 

Definition.  A  chronic  progressive  motor  paralysis  and  atrophy 
of  certain  groups  of  muscles.  The  paralysis  proportionate  to  the 
wasting  or  fibrillary  atrophy. 

Causes,    Most  frequent  in  males  between  twenty-five  and  fifty 


DISEASES   OF  THE  SPINAL  CORD.  463 

years  of  age,  and  in  many  instances  is  hereditary.  A  predis- 
position seems  to  exist  in  those  who  habitually  use  one  set  of 
muscles  (muscular  strain).  Exposure  to  cold  and  damp;  lead; 
syphilis ;  injuries  to  the  spinal  column.  Following  such  acute 
diseases  as  diphtheria,  measles,  acute  rheumatism,  typhoid  and 
typhus  fevers. 

Pathological  Anatomy.  Two  theories  as  to  the  origin  of  the 
pathological  changes  are  held :  one  that  the  initial  lesion  is  in  the 
cord  (Charcot),  the  other  in  the  muscular  interstitial  connective  tissue 
(Friedreich). 

The  morbid  alterations  are  of  two  groups — spinal  and  muscular. 

The  spinal  changes  consist  in  the  atrophy  and  degeneration  of  the 
anterior  columns,  wasting  and  disappearance  of  the  multipolar  gan- 
glion cells  of  the  anterior  horns,  with  hyperplasia  of  the  neuroglia; 
rarely,  the  hyperplasia  extends  to  the  lateral  columns  (amyotrophic 
lateral  sclerosis) ;  also  wasting,  atrophy,  and  degeneration  of  the 
anterior  nerve  roots. 

The  muscular  changes  consist  of  a  progressive  wasting  of  the  mus- 
cular tissue,  with  increase  of  the  interstitial  connective  tissue.  "  The 
final  result  is  that  the  muscle  is  converted  into  a  mere  fibrous  bard 
with  numerous  fat-cells,  the  development  of  this  latter  material  taking 
place  outside  of  the  muscular  elements  and  in  the  newly-formed 
connective  tissue  "  (Bartholow). 

Symptoras.  The  invasion  is  gradual,  the  disease  having  been 
in  progress  some  weeks  or  months  before  the  patient  is  aware  of  its 
existence. 

In  the  immense  majority  of  cases  the  disease  is  permanently  lim- 
ited to  one  or  a  few  groups  of  muscles  in  the  upper,  or  more  rarely  in 
the  lower,  extremities.  The  only  muscles  not  yet  known  to  be  at- 
tacked are  those  of  mastication  and  those  that  move  the  eyeball 
(Roberts). 

Fibrillary  contraction  is  an  early  symptom,  continuing  more  or 
less  marked  so  long  as  any  muscular  fibres  remain.  It  consists  of 
wave-like  7novements  of  the  muscles,  excited  automatically,  by 
draughts  of  air  or  percussion.  Coincident  with  the  wasting  is  loss  of 
power,  disorders  of  sensation,  coolness  and  pallor  of  the  surface. 
'The  natural  roundness  and  contour  of  the  body  and  limbs  are 
changed,  the  bones  standing  out  in  unaccustomed  distinctness,  giving 
the  individual  the  appearance  of  a  skeleton  clothed  in  skin. 


464  PRACTICE    OF    MEDICINE. 

Four  types  of  the  disease  are  recognized  :  i,  the  hand-type;  2,  the 
juvenile  type  ;  3,  the  infantile  facial  type  ;  4,  the  peroneal  type. 

The  hand-type :  uiasting  begins  in  the  hand,  and  particularly  in 
the  short  muscles  of  the  thumb  and  the  ball  of  the  little  finger — the 
thenar  and  hypoihenar  eminences.  The  complete  atrophy  of  the 
thumb  muscles  produces  such  a  change  in  the  shape  of  the  hand  as 
to  give  it  the  name  of  the  ape-hand.  Soon,  and  may  be  at  the  same 
time,  wasting  of  the  dorsal  interosseous  is  observed,  with  consequent 
loss  of  power  in  these  muscles,  producing  the  deformity  known  as 
claw-hand.  Soon  the  deltoid  and  other  arm  muscles  are  involved  in 
the  wasting  and  contraction. 

The  juvenile  type  (Erb) :  a  rare  form,  affecting  the  muscles  of  the 
shoulder  and  upper  arm,  and  less  commonly  the  muscles  of  the  lower 
extremities.  This  form  follows  after  a  time  in  the  hand-type,  but  Erb 
described  cases  occurring  primarily  in  these  parts.  Rarely,  wasting 
in  the  suprascapular  muscles,  with  fibrillary  contractions,  is  seen 
alone. 

The  infantile  facial  type:  involves  the  muscles  of  expression, 
changing  entirely  the  appearance  of  the  individual  and  giving  the 
eyeballs  a  prominence  from  atrophy  of  the  surrounding  muscles,  not 
unlike  exophthalmos.  After  a  time,  the  muscles  of  the  shoulder  and 
arm  are  involved,  except  the  supraspinalis,  infraspinalis,  and  the 
flexors  of  the  hand  and  fingers. 

The  peroneal  type  :  wasting  first  appears  in  the  muscles  of  the  legs, 
extending  to  the  feet,  producing  single  or  double  club-foot.  After  a 
time,  the  muscles  of  the  hands  and  arms  are  involved,  with  the  conse- 
quent deformities.     Vasomotor  changes  are  observed  in  this  type. 

Rarely,  all  the  types  are  more  or  less  blended  in  the  same  indi- 
vidual. Usually,  the  electro-contractility  is  preserved  so  long  as 
muscular  fibres  remain. 

Diagnosis.  When  wasting  palsy  is  fully  developed,  its  diagnosis 
is  a  simple  matter.  In  its  early  stages  a  doubt  may  exist,  but  atten- 
tion to  the  history,  symptoms,  and  progress  will  determine  the  ques- 
tion. 

Syringomyelia  often  begins  with  muscular  atrophy  as  a  marked 
symptom,  and  may  be  confounded  with  wasting  palsy,  the  chief  points 
of  distinction  between  which  are  :  the  loss  of  power  of  perceiving  heat, 
or,  often,  to  distinguish  between  heat  and  cold,  and  the  appearance 
of  trophic  changes,  such  as  a  dusky  or  purplish  hue  of  the  hands, 


DISEASES   OF   THE   SPINAL   CORD.  465 

with  a  uniform  tliickness  resembling  myxoedema,  the  development  of 
blebs  and  ulcers,  and  changes  in  the  nails.  Arthropathies  are  some- 
times met  with. 

Prognosis.  A^ery  unfavorable,  although  the  danger  to  life  is  often 
very  remote.  The  disease  may  be  arrested  and  remain  stationary  for 
years. 

Treatment.  Internal  medication  seems  to  have  no  effect  on  the 
malady,  although  if  mineral  poisoning  be  suspected,  ^ofasszt  zodidi/m 
should  be  employed,  and  if  syphilis  be  suspected,  a  course  oi potassii 
iodiduin  and  hydrargyru7n  should  be  administered.  Arsenuiun, 
strychnine  sulphas,  and  oleum  morrhuce,  with  a  generous  diet,  are 
amongst  the  remedies  indicated. 

If  the  disease  is  the  result  of  overworking  any  set  of  muscles,  these 
must  be  allowed  a  rest. 

"  The  most  effective  remedy  in  wasting  palsy  is,  undoubtedly,  ^a/- 
vanisjn.  Numerous  observations  attest  its  value  when  applied  locally 
to  the  affected  muscles  "  (Roberts). 

I  have  seen  improvement  from  Xhefaradic  current  to  the  affected 
muscles,  the  strength  being  simply  sufficient  to  produce  contractions. 

Massage  is  a  valuable  adjuvant  to  the  electrical  treatment,  as  are 
hot  sponging  and  rubbing  along  the  spine. 

Prof.  Bartholow  "  has  apparently  effected  great  improvement  in  a 
case,  confined  as  yet  to  the  left  upper  extremity,  by  the  injection 
of  glycerin  solution  into  the  wasting  muscles." 


SPINAL  SCLEROSIS. 

Synonym.     Duchenne's  disease. 

Definition.  A  myelitis  ;  an  increase  in  the  connective  tissue  of 
the  spinal  cord,  with  atrophy  of  the  nerve  structure  proper. 

Varieties.  I.  Lateral  sclerosis.  II.  Posterior  sclerosis,  or  loco- 
motor ataxia.     111.  Ataxic  paraplegia.     IV.  Cerebro-spijial sclerosis. 

Causes.  Generally  a  hereditary  neuropathic  diathesis  ;  syphilis; 
alcoholism  ;  mineral  poisons  ;  shock  or  injuries  to  the  cord  ;  exposure 
to  cold  and  wet ;  mostly  occurring  between  the  ages  of  thirty-five  and 
fifty-five ;  males  more  liable  than  females.  It  is  said  that  railroad 
enginemen  and  firemen,  as  well  as  conductors  and  other  trainmen, 
suffer  from  this  and  other  spinal  diseases  by  reason  of  the  continual 

30 


466  PRACTICE    OF    MEDICINE. 

concussion  of  railway  travel.  The  freedom  from  the  disease  in  the 
negro  has  been  noted  by  Mitchell. 

Pathological  Anatomy.  The  chan<jes  in  the  cord  are  gradual 
in  their  development  and  follow  a  longitudinal  instead  of  a  transverse 
direction. 

The  form,  consistency,  and  color  of  the  cord  are  altered,  it  being 
atrophied,  indurated,  and  of  a  grayish  color. 

The  changes  are  hyperplasiaof  the  connective  tissue,  with  granular 
degeneration,  atrophy,  and  disappearance  of  the  proper  nerve  ele- 
ments. The  nerve  roots  undergo  the  same  fibroid  change.  The 
joints  undergo  remarkable  atrophic  degeneration — the  arthropathies 
or  Charcot  joints,  consisting  of  an  osseous  hyperplasia,  the  joint 
enlarging  to  an  enormous  extent. 


PRIMARY  LATERAL  SCLEROSIS. 

Synonyms.  Antero-lateral  sclerosis;  spasmodic  tabes  dorsalis 
(Charcot)  ;  spastic  spinal  paralysis  (Erb). 

Definition.  A  degeneration  of  the  lateral  columns  of  the  cord; 
characterized  by  paraplegia,  contractures  of  the  muscles,  with  exag- 
gerated reflexes. 

Pathogeny.  The  exact  morbid  condition  is  still  a  subject  of  dis- 
cussion. The  site  of  the  lesion  is  the  lateral  while  columns,  in  some 
cases  extending  to  the  anterior  horn,  and  involving  the  whole  length 
of  the  cord.  The  changes  consist  in  an  interstitial  hyperplasia  of  the 
connective  tissue,  and  an  atrophy  of  the  nerve  elements. 

Symptoms.  The  onset  of  the  disease  is  very  gradual,  with  in- 
creasing feeling  of  heaviness  and  weakness  in  the  limbs,  progressing 
to  a  com-p\t\.e.  paraplegia.  There  are  aXso  jctkifig  and  Switching  with 
cravips  and  stiffness  of  the  muscles  of  the  paretic  limbs.  The  spasms 
of  the  legs  gradually  increase  in  extent  as  the  power  lessens,  until  at 
last  the  legs,  whenever  extended,  pass  into  a  condition  of  strong 
extensor  spasm,  rigidly  fixing  them  to  the  pelvis,  so  that  the  patient 
lies  rigid  ;  if  one  leg  is  lifted  from  the  couch  by  the  observer,  the  other 
leg  is  moved  also.  The  spasm  may  be  such  that  the  knee  cannot  be 
passively  flexed  by  any  force  that  can  be  applied  to  it  until  the  spasm 
has  lessened.  When  flexed,  the  limb  is  comparatively  supple; 
but  if  it  is  then  extended,  the  spasm  instantly  returns,  making  the 


DISEASES   OF  THE  SPINAL  CORD. 


46^ 


limb  rigid,  and  often  completing  the  extension,  just  as  the  blade  of  a 
knife  opens  out  under  the  influence  of  its  spring,  "clasp-knife 
rigidity."  Occasionally,  there  occur  brief  flexor  spasms,  drawing  the 
legs  up. 

Seguin  called  attention  to  "a  desire  to  micturate  that  is  far  less 
controllable  than  it  should  be  in  a  healthy  person." 

The  knee-jerk  is  greatly  exaggerated,  and  there  can  also  be  devel- 
oped rectus-clonus  and  ankle-clonus. 

The  spastic  gait  is  characteristic,  termed  by  Hammond  "  the  wad- 
dle" ;  the  legs  drag  behind  and  are  moved  forward  as  a  rigid  whole, 
the  toes  catching  against  the  ground,  the  patient  showing  a  tendency 
to  fall  forward. 

Sensation  is  unaffected.  As  the  morbid  process  extends  upward, 
the  superior  extremities  suffer  in  the  same  manner  as  those  of  the 
lower. 

Electro-contractility  early  impaired  and  gradually  declining  until 
abolished. 

Diagnosis.  The  gradual  development  of  weakness  in  the  legs, 
excess  of  myotatic  irritability,  and  spasms  with  developing  spastic  gait 
render  the  diagnosis  clear.  If  the  symptoms  develop  suddenly  or 
acutely,  the  morbid  condition  is  not  of  the  degenerative  variety. 

Prognosis.  Complete  recovery  rare.  If  the  condition  is  early 
recognized,  its  progress  may  be  held  in  check  for  a  long  time. 

Treatment.  Rest  of  the  first  importance.  Every  means  to  pro- 
mote the  general  health.  If  the  result  of  lues  or  mineral  poisons, 
increasing  doses  of  potassii  iodiduin,  or  aurii  et  sodii  chloridum. 
Argenti  nitras ,  or  oxidiim,  often  retards  the  hyperplasia  of  connective 
tissue.  Benefit  may  sometimes  follow  the  use  of  a  weak  galvanic 
current,  but  as  a  rule  electricity  is  disappointing  in  central  diseases. 


LOCOMOTOR  ATAXIA. 

Synonyms.     Posterior  spinal  sclerosis ;  tabes  dorsalis. 

Definition.  A  chronic  degeneration  of  the  posterior  columns  of 
the  spinal  cord  and  the  posterior  nerve  roots,  characterized  by  loss 
of  co-ordination,  neuralgic  pains  in  the  limbs,  loss  of  sensation  and 
reflexes,  and  visceral  and  trophic  changes. 

Pathogeny.    "  A  general  disease  of  the  nervous  system,  affecting 


4()8  PRACTICE    OF    MEDICINE. 

both  central  and  peripheral  portions,  though  mainly  limited  to  sensory 
or  afferent  structures"  (Peterson).  "A  progressive  destructive  pro- 
cess which  has  a  selective  influence  on  certain  tracts  in  the  posterior 
columns  with  their  roots  and  ganglia  and  to  a  less  extent  on  the 
peripheral  nerves,  particularly  the  optic.  The  nerve  fibres  of  the  cord 
are  first  involved.  Their  destruction  is  not  a  simple  wasting,  but  is 
accompanied  with  evidence  of  irritation,  such  as  swelling  of  axis- 
cylinders  and,  secondarily,  proliferation  of  connective  tissue  and 
slight  congestion  "  (Dana). 

Symptoms.  Locomotor  ataxia  may  be  divided  into  three  periods  : 
I,  disturbances  of  sensation  ;  2,  loss  of  co-ordinating  power;  3,  paralysis. 

The  onset  of  the  disease  is  gradual,  by  sharp,  darting,  electric-like 
pains  in  the  lower  limbs,  with  disorders  of  the  gastro-intestinal  and 
genito-urinary  tracts.  Associated  with  the  pains  is  a  loss  of  sensation 
in  the  feet,  the  patient  being  unable  to  distinguish  between  hard  and 
soft  substances  in  walking,  and,  if  the  upper  portion  of  the  spinal 
cord  be  affected,  is  unable  to  co-ordinate  the  muscles  of  the  fingers 
sufficiently  to  button  his  clothing.  A  sensation  of  formication  over 
the  surface,  especially  over  the  lower  limbs,  and  about  the  waist,  the 
knee,  and  the  ankle,  is  present ;  there  is  nearly  always  a  feeling  of 
constriction  about  the  trunk — the  girdle. 

Loss  of  co-ordination,  or  ataxia,  the  subject  being  unable  to  walk 
upon  a  straight  line  with  his  eyes  closed,  and  with  difficulty  if  his 
eyes  are  opened.  Inability  to  preserve  the  erect  position  with  the 
feet  close  together,  the  body  swaying  widely  and  the  patient  falling 
on  standing  with  closed  eyes, — Romberg's  symptom,  and  as  the 
malady  progresses  he  throws  his  feet  and  legs  in  the  most  grotesque 
manner  when  walking.  Although  the  patient  is  unable  to  co-ordinate 
the  muscles,  their  power  is  not  lost,  for,  on  being  supported,  he  can 
kick  or  strike  with  his  usual  force. 

The  sight  is  early  impaired,  due  to  atrophy  of  the  optic  nerve,  caus- 
ing either  double  vision  or  inability  to  distinguish  between  different 
colors.  Very  early  there  is  loss  of  pupil  reflex  to  light,  the  reaction  to 
accommodation  being  present — Argyll- Robertson  symptom.  As  the 
disease  progresses,  sensation  becomes  more  and  more  blunted  and 
pain  is  slowly  recognized,  frequently  several  minutes  elapijing  before 
the  pricking  of  a  pin  is  appreciated.  A  characteristic  sign  of  the 
disease  is  the  abolition  of  the  patellar  tendon  rrflex — Westphal's 
symptom — as  well  as  other  reflexes  in  the  lower  limbs.     Loss  of  the 


DISEASES   OF  THE   SPINAL   CORD.  '  .469 

sensation  of  temperature  also  occurs.  The  electro-contractiliiy  is 
decreased  in  the  affected  hmb.     General  emaciation  is  marked. 

Vasomotor  and  trophic  symptoms,  more  or  less  pronounced,  occur 
in  all  cases.  "  Perforating  ulcers"  of  the  feet,  loss  of  hair  in  spots, 
changes  in  the  nails,  and  local  sweatings  are  the  more  common. 
Muscular  atrophy,  either  localized  or  general,  is  not  infrequent. 

Frankel,  under  the  term  "  hypotonia,"  describes  a  condition  found 
in  tabetic  persons  in  which  the  patient,  lying  on  a  flat  surface,  can  com- 
pletely straighten  his  legs  when  at  right  angles  to  the  body,  which  can- 
not be  done  by  a  normal  man,  whose  knees  will  be  bent  when  legs 
are  at  right  angles  with  body. 

Either  early  or  late  in  the  disease  occur  disturbances  in  micturition 
and  loss  of  sexual  power  and  often  desire.  There  also  occur,  in  a 
fair  number  of  Cdises,  painless  swelling  d^nd  disintegration  of  various 
joints,  particularly  the  knee  and  elbow — the  tabetic  arthropathies,  or 
Charcot  joints. 

At  any  period  of  the  disease  peculiar  crises  or  neuralgic  attacks 
occur ;  if  griping  pains  in  stomach  with  vomiting,  gastric  crises ;  if 
renal  pain  or  colic  with  disturbed  urinary  flow,  nephralgic  crises  ;  if 
pain  in  bladder,  vesical  crises ;  if  pain  in  rectum  with  haemorrhoids, 
rectal  crises;  if  severe  paroxysm  of  coughing,  bronchial  crises;  if 
constriction  of  the  throat  with  dyspnoea,  laryngeal  crises  ;  if  cardiac 
pain  and  tachycardia,  cardiac  crises. 

Paralysis  finally  ends  the  suffering  of  the  patient.  There  is  gener- 
ally an  entire  absence  of  cerebral  phenomena,  although  rarely  delu- 
sions or  dementia  develop  toward  the  end  of  the  malady. 

Diagnosis.  There  are  three  pathognomonic  symptoms  of  loco- 
motor ataxia,  the  presence  of  which  makes  the  diagnosis  positive ;  they 
are  Westphal's  symptom — absence  of  patellar  reflex  ;  Romberg's 
symptom — swaying  of  body  and  inability  to  maintain  erect  position 
with  closed  eyes  ;  the  Argyll-Robertson  symptom — loss  of  pupil  reflex 
to  light,  but  reaction  to  accommodation  retained  ;  Frankel's  symptom 
— hypotonia. 

Chronic  myelitis  is  characterized  by  paralysis,  and  the  course  of 
the  affections  are  otherwise  so  different  that  an  error  should  not  occur. 

Disease  of  the  cerebellum  presents  symptoms  of  disordered  co-ordi- 
nation, but  they  are  the  result  of  vertigo,  and  associated  with  headache, 
nausea,  and  vomiting,  with  absent  neuralgic  pains  and  eye  symptoms. 

Paraplegia  is  a  true  paralysis,  while  locomotor  ataxia  is  not.  Neu- 
ralgic pain  is  not  a  symptom  of  paraplegia. 


470  ■  PRACTICE   OF   MEDICINE. 

MulUpU  neuritis  shows  loss  of  power  with  pain,  but  does  not  present 
the  three  pathognomonic  symptoms  mentioned  above. 

Prognosis.  Unfavorable.  Rarely  the  progress  has  been  retarded 
for  a  long  time.  There  are  some  claims  of  recoveries  of  locomotor 
ataxia  in  the  early  stage,  but  that  a  cure  of  a  genuine  case,  extending 
to  the  second  stage,  is  ever  effected  seems  very  questionable. 

Treatment.  In  the  management  of  locomotor  ataxia,  rest,  as 
nearly  absolute  as  possible,  is  of  the  first  importance.  It  will  be  all 
the  more  effective  if  it  be  in  bed  for  a  period  of  several  months. 

Following  the  suggestion  of  Erb,  use  may  be  made  of  cold  along 
the  spine,  in  the  shape  of  cold  sponging,  cold  spinal  pack,  or  short 
applications  of  the  cold  douche  to  the  spine.  T\\t galvanic  continuous 
current  along  the  spinal  column  is  warmly  advocated,  with  faradism 
to  the  wasting  muscles. 

Potassii  iodidum,  or  hydrargyri  chloridum  corrosivum,  in  full  doses, 
or  aurii  et  sodii  chloridum,  gr.  -^^  (0.003  Gm.),  three  times  a  day,  often 
remarkably  retard  the  progress  of  the  affection.  The  best  results  are 
obtained,  however,  from  argenii  nitras,gr.  %-%.  (o  016-0.03  Gm.), 
or  oxidum,  gr.  yz  (0.03  Gm.),  three  times  a  day,  withholding  it  at 
intervals  of  a  few  weeks  to  prevent  discoloration  of  the  skin  (argyria). 

Temporary  success  at  least  seems  to  have  followed,  in  some  cases 
of  locomotor  ataxia  in  the  second  stage,  from  the  "suspension  treat- 
victif'  recommended  by  Charcot.  The  treatment  consists  in  the 
suspension  of  the  patient  during  a  period  varying  from  one  to  four 
minutes,  by  means  of  the  Sayre  apparatus  for  applying  the  plaster 
jacket  in  spinal  deformities. 

The  severe  and  sharp  pains  require  treatment,  at  first  giving  prefer- 
ence to  any  of  the  substitutes  of  opium,  but  finally  opitan  itself  will 
have  to  be  resorted  to.  The  actual  cautery  applied  to  the  back  once 
a  month  is  said  to  relieve  the  pains. 

The  diet  should  be  of  a  nutritious,  easily-assimilated  character. 
Nutrition  can  also  be  promoted  by  the  use  of  oleum  morrhucE,  and 
syrupus  calcii  lacto-phosphatis,  or  the  hypophosphites  and  strychnina. 

ATAXIC   PARAPLEGIA. 

Synonyms.  Combined  lateral  and  posterior  sclerosis  ;  antero- 
lateral sclerosis. 

Definition.     A   chronic   degeneration    of  the   lateral   pyramidal 


DISEASES   OF  THE  SPINAL   CORD.  471 

tracts  and  of  the  posterior  columns  of  the  spinal  cord  ;  characterized 
by  gradually  developing  paraplegia,  with  ataxia  and  spasms  of  the 
limbs. 

Causes.  The  causes  are  not  so  well  determined  as  in  other  vari- 
eties of  spinal  sclerosis. 

Pathogeny.  A  sclerosis  of  the  lateral  and  posterior  columns  of 
the  spinal  cord.  It  is  to  be  noted  that  the  posterior  columns  show 
the  morbid  changes  higher  up  than  in  locomotor  ataxia, — the  dorsal 
rather  than  the  lumbar  regions, — and  that  the  root-zone  of  the  postero- 
external column  is  much  less  involved.  Nor  do  the  lateral  tracts 
show  the  same  degree  of  involvement  as  in  spastic  paraplegia. 

Symptoms.  The  onset  is  slow  and  gradual,  with  loss  of  power 
in  the  lower  extremities.  The  muscles  involved  are  particularly  the 
flexors  of  the  thigh  and  knee.  One  leg  may  be  weaker  than  the  other. 
There  is  also  ataxia,  the  patient  being  unsteady  when  standing  with 
feet  together  (tabetic  swaying),  and  he  tends  to  fall  if  the  eyes  are  at 
the  same  time  closed.  Spasms  of  the  lower  extremity  gradually  de- 
velop and  finally  become  as  marked  as  in  spastic  paraplegia.  The 
knee  jerk  reflex  is  increased,  quick  and  extensive,  and  rectus-  and 
ankle-clonus  can  be  developed.  The  sexual  power  is  early  lost.  In- 
continence of  urine  is  frequent.  Sensation  is  imi^npaired  and  neu- 
ralgic pains  are  absent,  as  are  eye  symptoms. 

Diagnosis.  The  conditions  ataxic  paraplegia  is  most  liable  to 
be  mistaken  for  are  locomotor  ataxia  and  spastic  paraplegia.  The 
presence  of  knee-jerk  and  loss  of  power  in  lower  extremities  are  of 
value  in  discriminating  from  locomotor  ataxia.  Spastic  paraplegia 
is  not  associated  with  ataxia — indeed,  ataxic  paraplegia  is  spastic 
paraplegia ^/z^^  inco-ordination. 

Prognosis.     Unfavorable.     The  condition  is  progressive. 

Treatment.  The  same  plan  of  treatment  may  be  tried  as  recom- 
mended for  lateral  or  posterior  sclerosis. 


CEREBRO-SPINAL  SCLEROSIS. 

Synonyms.  Multiple  sclerosis  of  the  brain  and  cord ;  cerebral 
sclerosis  ;  spinal  sclerosis  ;  disseminated  sclerosis  (Charcot). 

Definition.  A  degenerative  disease  of  the  brain  and  spinal  cord  ; 
characterized  by  pains  in  the  back,  disorders  of  sensation,  loss  of 


472  PRACTICE    OF    MIcniClNE. 

co-ordination,  tremor  on  motion,  scanning  speech,  and  some  mental 
impairment. 

Pathogeny.  The  disease  consists  in  the  development  of  patches 
of  j^rayish,  translucent,  tough  nodules,  varying  in  size  from  a  minute 
microscopical  object  up  to  the  size  of  a  walnut,  varying  in  number 
and  widely  distributed  in  the  white  matter  of  the  hemispheres,  ven- 
tricles, optic  thalamus,  corpus  striatum,  peduncles,  pons,  and  cere- 
bellum, while  in  the  cord  they  are  found  in  both  the  white  and  gray 
matter  and  in  the  columns.  The  deposits  are  also  found  in  the  nerve 
roots  and  nerve  trunks.  The  nodules  are  composed  of  the  neuroglia, 
much  altered,  and  a  newly-formed  connective  tissue.  The  result  of 
the  growth  of  the  nodules  is  pressure  upon  the  nerve  structure,  ending 
in  its  degeneration. 

Symptoms.  Charcot  divided  disseminated  sclerosis  into  three 
varieties,  depending  upon  the  site  of  the  marked  changes,  as  the 
brain,  the  cord,  or  a  combination  of  the  two.  The  latter  variety  is 
the  more  common. 

Rarely,  the  malady  is  ushered  in  with  apoplectiform  symptoms,  but 
generally  the  onset  is  insidious,  with  pains  more  or  less  severe  in  the 
limbs  and  back,  which  are  attributed  by  the  patient  to  rheumatism. 
Also  a  feeling  of  formication,  itching,  and  burning  in  the  limbs.  Loss 
of  co-ordination  of  the  hands  in  writing,  or  the  feet  in  walking,  or  a 
jerky  co-ordination,  followed  after  a  time  by  paresis,  more  or  less 
general,  with  coitractiire  of  the  muscles.  Voluntary  movements  of 
the  paretic  limbs  develop  a  iretnor — the  shaking  tremor — which  sub- 
sides when  the  limbs  are  at  rest — intention  tremor,  with  shaking  of 
head.  An  early  and  frequent  condition  is  nystagmtis.  The  loss  of 
co-ordination,  with  tremor  and  with  contractures  of  the  muscles 
of  the  legs,  has  given  rise  to  the  "waddle,"  or  "hop"  gait  when 
walking.  There  are  also  present  headache,  vertigo,  mental  impair' 
ment,  with  an  unnatural  contentment  of  the  feelings  and  with  the 
surroundings.  A  scanning  or  slurring  speech  ;  disorders  of  vision, 
from  optic-nerve  atrophy,  and  hearing ;  sexual  disturbances,  vesical 
disorders,  gastric  and  other  crises,  and  often  the  development  of 
bed-sores. 

Knee-jerk  and  wrist-jerk  are  exaggerated,  and  ankle-clonus  is 
present. 

The  disease  is  progressive,  the  symptoms  developing  as  the  various 
nerve  tracts  are  invaded. 


DISEASES   OF  THE   SPINAL   CORD.  473 

Persons  with  multiple  sclerosis  are  very  liable  to  develop  pulmonary 
consumption  or  chronic  nephritis. 

Duration.  Ranges  from  a  year  to  twenty  years,  an  average 
being  five  or  ten  years. 

Diagnosis.  Keeping  in  mind  the  following  general  symptoms 
an  error  can  be  avoided  :  pains  in  limbs  and  back,  loss  of  co-ordina- 
tion in  the  feet  and  hands,  muscular  weakness  with  contractures, 
intentional  tremor,  nystagmus,  scanning  speech,  disordered  vision, 
increased  tendon  reflexes,  and  vertigo. 

Paralysis  agitans  may  be  mistaken  for  disseminated  sclerosis. 
The  chief  points  in  the  diagnosis  are  the  presence  in  paralysis 
agitans  of  the  fine  treinor  continually  without  shaking  of  the  head, 
with  a  peculiar  flexion  and  rigidity  of  the  hand,  while  in  cerebro- 
spinal sclerosis  the  tremor  is  produced  only  on  movement  of  the 
muscle,  and  is  associated  with  shaking  of  the  head.  Paralysis 
agitans,  a  disease  of  middle  life,  sclerosis  under  forty  years.  Changes 
in  the  voice,  speech,  and  vision  are  present  in  cerebro-spinal  sclerosis, 
but  absent  in  paralysis  agitans. 

Tumor  of  the  p07is  or  c?-us  is  accompanied  with  wild,  jerky  inco- 
ordination closely  resembling  disseminated  sclerosis,  but  tumor  also 
has  headache,  vomiting,  optic  neuritis,  local  spasm,  and  local 
paralysis. 

Ge7ieral  paralysis  of  the  insane  and  disseminated  sclerosis  are  fre- 
quently confounded,  as  are  locomotor  ataxia  and  primary  lateral 
sclerosis. 

Prognosis.  Unfavorable.  The  disease  slowly  but  steadily  pro- 
gresses, chronic  nephritis  or  tuberculosis  frequently  developing  and 
causing  death. 

Treatment.  There  is  no  drug  having  the  power  to  cure  sclerosis. 
Syphilis  has  been  the  cause  of  the  vast  majority,  if  hot  all,  of  the  cases 
observed  by  the  writer,  and  poiassii  iodidum,  in  large  doses,  or  the 
following  has  seemed  in  a  few  instances  to  hold  the  disease  in  check 
for  a  time  : 

U .     Hydrargyri  chloridi  corros. ,     .    .    gr.  j  .065  Gm. 

Liq.  arsenici  chloridi, f.:^j  4.  Cc. 

Inf.   gentian., ad  f  3  iij  ad  90.  Cc.      M. 

SiG. — Teaspoonful  three  times  daily,  in  water. 

Attention  to  the  general  health  and  remedies  to  promote  con- 
structive metamorphosis  will  prolong  life  and  add  to  the  comfort  of 
the  individual. 


474  PRACTICE    OF    MliDlCINE. 


SYRINGOMYELIA. 

Synonym.     Syringomyelilis. 

Definition.  A  chronic  disease  of  the  spinal  cord,  characterized 
by  the  formation  of  cavities  in  the  substance  of  the  cord,  associated 
with  loss  of  the  perception  of  pain  and  temperature  over  certain 
regions,  and  complicated  with  muscular  weakness  and  atrophy,  and, 
at  times,  trophic  changes. 

Causes.  Not  a  frequent  condition.  Seen  oftener  in  men  than  in 
women.  The  etiological  factors  not  determined.  It  is  a  disease  of 
early  life,  beginning  before  thirty. 

Pathological  Anatomy.  There  are  present  a  tubular  cavity 
or  cavities  in  the  substance  of  the  spinal  cord.  There  is  considerable 
difference  of  opinion  as  to  how  these  cavities  develop.  It  is  thought 
that  they  may  originate  in  either  "  a  faulty  closure  of  one  of  the 
divisions  of  the  primary  central  canal  of  the  cord,  for  in  the  course  of 
development  the  primary  central  canal  of  the  cord  becomes  divided 
into  two  parts — an  anterior  and  a  posterior.  The  anterior  division 
forms  the  permanent  central  canal.  The  walls  of  the  posterior  divi- 
sion gradually  come  together  and  form  the  posterior  fissure.  The 
imperfect  closure  of  either  of  these  divisions  of  the  primary  cen- 
tral canal  may  give  rise  to  syringomyelia.  Or,  the  abnormal 
cavity  or  cavities  may  depend  on  the  disintegration  of  a  gliomatous 
formation  which  originates  generally  in  embryonal  tissue  about  the 
central  canal.  The  cavity  varies  in  extent  and  location  in  difi"erent 
cases,  80  that  it  is  possible  to  find  marked  evidences  on  autopsy 
which  presented  no  symptoms  during  the  lifetime  of  the  individual. 
But  usually  the  cervical  cord  is  the  seat  of  the  disease. 

Symptoms.  The  condition  develops  slowly  and  insidiouslv. 
and  nearly  always  bilaterally.  There  occur  loss  or  diminution  of 
the  perception  of  temperature  (heat  and  cold)  and  pain,  the  tactile 
sense  being  ret. line d ;  slowly  developing  muscular  atrophy,  due  to 
involvement  of  the  anterior  horns  of  the  cord.  The  atrophy  usu- 
ally affects  the  arm  and  shoulder  of  one  or  both  sides,  and  it  may 
begin  in  the  hand.  Associated  with  the  muscular  atrophy  is  muscu- 
lar weakness  and  more  or  less  fibrillary  contractions.  When  the 
weakness  involves  the  spinal  muscles,  scoliosis  occurs.  Arthro- 
pathies occur  in   many  cases,  particularly  involving  the  shoulder- 


DISEASES   OF  THE   NERVES.  475 

joint.  Trophic  changes  also  involve  the  skin,  often  advancing  to 
ulceration  and  even  gangrene,  and  rarely  to  painless  felons,  such  as 
occur  in  Morvan's  disease. 

The  disease  is  seen  in  many  irregular  types,  the  loss  of  temperature 
sense  in  one  part  and  the  loss  of  sensation  of  pain  in  another,  and 
other  irregular  distribution  of  the  characteristic  phenomena. 

The  general  health  of  patients  suffer  but  little  in  syringomyelia. 

Diagnosis.  Progressive  muscular  atrophy  is  apt  to  be  confounded 
with  syringomyelia  unless  the  changes  in  the  temperature  and  pain 
senses  are  remembered.  Morvan's  disease  is  by  many  neurologists 
classed  as  a  variety  of  syringomyelia. 

Prognosis.  Incurable,  but  of  long  duration  ;  often  many  years, 
with  periods  of  quiescence. 

Treatment.     Entirely  symptomatic. 


DISEASES  OF  THE  NERVES. 


SIMPLE  NEURITIS. 

Definition.  An  inflammation  of  the  nerve  trunks  ;  characterized 
by  pain,  impaired  sensation,  motor  paralysis,  and  atrophy. 

Causes.  Wounds  and  injuries  or  compression  of  nerves ;  cold 
and  damp  ;  syphilis  (?)  ;  lead. 

Pathological  Anatomy.  Hypersemia,  followed  by  exudation 
into  the  nerve  sheath  and  connective  tissue,  "  which  becomes  softened 
and  ultimately  breaks  down  into  a  diffluent  mass."  Migration  of 
white  corpuscles  takes  place  into  the  neurilemma.  Recovery  may 
occur  before  destruction  of  the  nerve  elements  is  produced,  absorp- 
tion of  the  exudation  occurring.  "  It  is  important  to  note  that  when 
inflammation  occurs  in  a  nerve  it  may  extend  from  the  point  first 
diseased  upward  {neuritis  ascendens)  or  downward  {iteuritis  descen- 
dens)^ 

Symptoms.  The  onset  may  be  accompanied  with  febrile  reac- 
tion.    The  most  decided  symptom  is  pain  along  the  course  of  the 


4T(i  PRACTICE    OF    MEDICINE. 

nerve  trunk  and  its  peripheral  distribution,  of  a  burning,  tingling, 
tenting,  intense  character,  increased  by  pressure  or  motion.  If  the 
affected  nerve  be  a  mixed  one, — sensory  and  motor, — spasmodic  con- 
tractions and  muscular  cramps  occur,  followed  by  impaired  motion, 
terminating  in  paresis  of  the  muscles  innervated  by  the  affected  trunk. 
The  sense  of  touch  and  of  pain  are  markedly  impaired,  while  the 
temperature  and  muscular  sense  are  but  slightly  disturbed. 

If  the  inflammation  proceed  to  destruction  of  the  nerve  trunk,  wast- 
ing and  degeneration  of  the  muscular  tissue  ensues.  Various  trophic 
changes  also  occur,  such  as  cutaneous  eruptions  and  clubbing  of  the 
nails.     The  electro  contractility  is  impaired  or  lost. 

Diagnosis.  Myalgia  or  muscular  pain  is  not  associated  with 
paralysis,  nor  does  the  pain  follow  the  course  of  a  nerve  trunk. 

Neuralgia  has  the  pain,  but,  as  a  rule,  not  the  tenderness  of  neuritis. 

Prognosis.     Generally  favorable,  with  proper  treatment. 

Treatment.  Repeated  ^/«/^rz>/o- along  the  course  of  the  nerve, 
preferably  with  the  Paquelin  cautery  or  a  poker  at  white  heat,  with 
full  doses  oi potassii  iodidum,  are  usually  successful.  Sodii  salicylas, 
phenacetin,  and  antifebrin  are  often  valuable,  but  for  severe  pain  no 
drug  is  to  be  compared  with  morphincB  sulphas  by  the  hypodermic 
method.  From  the  onset  quinines  sulphas,  gr.  ij-v  (0.13-0.3  Gm.) 
every  four  hours,  is  most  valuable,  and  if  the  attack  be  due  to  exposure 
to  cold  or  damp,  combine  sodii  salicylas,  gr.  ij-v  (0.13-0.3  Gm.),  in 
capsule. 

As  the  more  acute  symptoms  subside,  the  use  of  galvanism  or  a 
feeble,  slowly  interrupted  faradic  current  restores  the  disordered 
function  of  nerve  and  muscle. 

If  anaemia  be  present,  make  use  oiferrutn,  with  malt  and  the  hypo- 
phosphites. 

MULTIPLE  NEURITIS. 

Synonyms.  Polyneuritis;  peripheral  neuritis;  disseminated 
neuritis;  degenerative  neuritis;  pseudo-tabes;  alcoholic  paralysis; 
beri-beri  (Brazil  and  India) ;  kakke  (Japan). 

Definition.  A  parenchymatous  inflammation  of  a  number  of 
symmetrical  peripheral  nerves,  simultaneously  or  in  rapid  succes- 
sion ;  characterized  by  pain,  numbness,  loss  of  power,  or  ataxia,  with 
muscular  atrophy.     Mental  symptoms  are  often  associated. 


DISEASES   OF   THE   NERVES.  477 

Causes.  Alcoholism;  syphilis;  malaria;  lead,  arsenic,  or  silver ; 
following  diphtheria,  typhoid  fever,  and  rheumatism. 

Beriberi  and  kakke  are  epidemic  varieties  of  multiple  neuritis,  the 
result  of  a  special  poison. 

The  probability  is  that  the  various  causes  named  develop  in  the 
blood  a  poison,  having  a  particular  susceptibility  or  "  selective 
action  "  for  nerve-fibres. 

Pathological  Anatomy.  The  affection  is  generally  bilateral 
and  symmetrical.  An  important  characteristic  is  its  peripheral  dis- 
tribution, the  inflammation  being  most  intense  at  the  extremities  of 
the  nerves,  lessening  progressively  toward  the  centre,  usually  termi- 
nating before  the  nerve  roots  are  reached.  The  inflammatory  process 
affects  the  nerve-fibres  primarily  and  the  sheath  and  connective-tissue 
secondarily — a  parenchymatous  inflammation.  The  affected  muscles 
are  paler  and  smaller  than  normal,  the  fibres  reduced  in  size  and 
undergoing  granular  changes. 

Symptoms.  All  plans  yet  suggested  for  classifying  the  varieties 
of  multiple  neuritis  are  imperfect.  The  onset  may  be  sudden,  even 
overwhelming,  causing  rapid  death,  but  is  usually  subacute  or 
chronic  in  its  course,  the  symptoms  being  wide-spread  in  proportion 
to  the  acuteness,  intensity,  and  cause  of  the  malady.  The  symptoms 
may  be  described  under  three  forms — a  motor,  a  sensory,  and  an 
ataxic  fortn. 

The  motor  form  shows  motor  weakness,  chiefly  involving  the 
flexors  of  the  ankles,  the  extensors  of  the  toes,  and  the  extensors  of 
the  wrist  and  fingers  in  the  forearms.  Inflammation  of  the  anterior 
tibial  or  peroneal  nerve  in  the  leg,  and  the  radial  branch  of  the 
musculo-spiral  in  the  arm,  resulting  in  the  double  "foot-drop" 
and  "wrist-drop"  so  characteristic  of  this  disease.  Any  nerves  of 
the  body  may  be  affected,  the  symptoms  varying  with  the  particular 
nerves. 

The  sensory  form  shows  pains,  tenderness,  tingling,  and  numbness 
with  loss  of  cutaneous  sensibility. 

At  times  the  hypersesthesia  of  the  extremities  is  so  marked,  and 
especially  that  of  the  soles  of  the  feet  and  the  muscles,  that  the  slightest 
touch  cannot  be  tolerated. 

The  ataxic  form  shows  inco-ordination  with  or  without  sensory 
disturbances,  but  with  loss  of  the  muscular  sense. 

The  forms  may  all  be  associated,  in  greater  or  less  extent,  in  any 
one  case. 


478  PRACTICE   OF    MEDICINE. 

Muscular  atrophy  begins  early  and  progresses  with  the  disease. 

The  knee-jerk  is  feeble  or  absent.  The  electro-contractility  is  feeble 
or  lost. 

In  alcoholic  cases,  there  may  be  delirium,  mania,  and  delusions, 
associated  with  tremors. 

Foot-drop  is  a  typical  symptom  in  alcoholic  neuritis. 

Trophic  changes  may  occur  in  the  nails,  hair,  and  skin.  The 
characteristic  glossy  condition  of  the  skin,  with  some  oedema,  is  due 
to  involvement  of  the  vaso-motor  nerves.  Rarely  the  vagus,  optic, 
and  laryngeal  nerves  are  involved. 

The  disease  may  be  ushered  in  with  fever,  ioi°  F.-i03°  F.  ;  rapid, 
feeble  pulse ;  headache,  nausea,  vomiting,  with  delirium  or  con- 
fusion. 

The  alcoholic  variety  affects  chiefly  all  the  limbs,  beginning  in  the 
flexors  of  the  feet ;  the  malarial,  the  legs  ;  diphtheria,  the  pharyngeal 
and  motors  of  the  eye;  rheumatic,  the  face;  and  lead,  the  arms. 

Beri-beri,  or  endemic  neuritis,  is  an  infectious  form  of  multiple 
neuritis  due  undoubtedly  to  micro-organisms.  It  is  claimed  that  some 
defect  in  diet  is  a  predisposing  cause  of  this  variety.  The  symptoms 
and  development  are  much  the  same  as  seen  in  other  varieties  with 
the  addition  of  ccdema  and  a  tendency  to  effusions  into  the  serous 
cavities  and  a  cardiac  involvement.  In  severe  cases  the  pain  is  in- 
tense and  the  wasting  rapid. 

Diagnosis,  In  no  disease  is  an  early  diagnosis  so  important  from 
a  therapeutical  standpoint.  Early  treatment  may  prevent  months  of 
suffering  and  idleness. 

Since  the  symptoms  of  this  wide-spread  affection  have  been  prop- 
erly separated  from  diseases  of  the  spinal  cord,  with  which  they 
were  formerly  always  associated,  the  diagnosis  is  very  readily  deter- 
mined. 

Loss  of  power  is  an  early  symptom,  usually  beginning  in  the  feet 
and  extending  upward  so  that  multiple  neuritis  may  be  mistaken  for 
Landry's  paralysis.  Ross  considers  these  affections  identical,  but 
usually  Landry's  paralysis  is  a  cord  disease. 

Prognosis.  As  a  rule,  favorable  if  early  and  proper  treatment  be 
instituted. 

Treatment.  Rest  is  of  the  greatest  importance  ;  the  more  thor- 
oughly this  is  carried  out,  the  better  will  be  the  results. 

Removal  of  the  cause  is  an  important  indication.     Warmth  to  the 


DISEASES   OF  THE   NERVES.  479 

affected  parts  by  flannel  next  to  the  skin,  hot  baths,  and  keeping  the 
parts  wrapped  in  cotton-wool. 

There  is  no  specific  drug  for  polyneuritis.  For  alcoholic  cases  use 
strychnines  nitras  ;  for  malarial  cases,  quiniticB  sulphas  ;  for  diphthe- 
ritic cases,  tinctura  ferri  chloridi  and  strychnincB  stdphas ;  for  rheu- 
matic cases,  sodii  salicylas,  salol,  or  phetiacetm  ;  for  syphilitic  cases, 
hydrargyrum  or  potassii  iodidutn  ;  for  lead  or  other  mineral  poison 
cases,  the  iodides ;  and  in  all  varieties,  tonics  with  a  generous  nutri- 
tious diet. 

Paift  should  be  relieved  with  either  ayttifebrin,  or  mo7'phiticE  sulphas, 
by  the  hypodermic  method.  As  convalescence  begins,  moderate 
exercise  and  mild  galvanism.  Arsenicuin  is  considered  the  best 
constructive  tonic  for  the  convalescence  of  multiple  neuritis. 

NEURALGIA. 

Definition.  A  disease  of  the  nervous  system,  manifesting  itself 
by  sudden  pain  of  a  sharp  and  darting  character,  mostly  unilateral, 
following  the  course  of  the  sensory  nerves. 

Varieties.  \.  Neuralgia  of  the  fifth  nerve;  II.  Cervico-occipital 
neuralgia ;  111.  Cervico-brachial  neuralgia ;  IV.  Dorso-intercostal 
neuralgia;  V.  Ltunbo-abdojninal  neuralgia;  VI.  Sciatica;  VII. 
Erythromelalgia  (Mitchell). 

Causes.  Hereditary.  Ansemia  ;  malaria  ;  syphilis  ;  metallic  poi- 
sons ;  anxiety  ;  mental  exertion  ;  exposure  to  cold  and  damp ;  in- 
juries of  a  nerve  trunk. 

Pathological  Anatomy.  The  old  axiom  of  neuralgia  being 
"  the  cry  of  the  nerves  for  pure  blood''  is  perhaps  only  part  of  the 
truth.  The  changes  in  the  nerve  trunks  or  centres  have  not  as  yet 
been  fully  determined.  A  fair  number  of  cases  present  the  changes 
of  neuritis. 

NEURALGIA   OF    THE   FIFTH    NERVE. 

Synonyms.     Tic-douloureux  ;_  Fothergill's  disease. 

Symptoms.  Paroxysmal  paiji,  of  a  sharp,  darting,  stabbing 
character,  most  common  at  points  along  the  course  of  the  supra- and 
infra-orbital  branches  of  the  fifth  nerve  of  the  left  side,  attended  with 
increased  lacrymation.  When  of  any  duration,  nutritive  changes  are 
observed  in  the  nervous  distribution,  such  as  cedetna  along  the  course 
of  the  nQxwe,  gray  eyebrows,  and  convulsive  twitches  of  the  muscles, 


480  PRACTICE    OF    MEDICINE. 

termed  "  tic-doitlonreux,"  tetiderness  at  the  infra-  and  supraorbital 
foramina,  as  well  as  along  the  course  of  the  nerve  distribution. 

CERVICO-OCCIPITAL   NEURALGIA. 

Symptoms.  Paroxysmal  pain,  of  a  sharp  and  lancinating,  or 
deep,  heavy,  tensive  character,  along  the  course  of  the  occipital  nerve 
upon  one  or  both  sides,  extending  from  the  vertex,  and  on  the  neck 
as  far  down  as  the  clavicle,  and  upward  and  forward  to  the  cheek. 
May  be  associated  with  hypercEsihesia  of  the  skin,  and  with  cramps  \n 
the  cervical  muscles,  and  with  attacks  of  herpes.  A  sensation  of 
cracki7ig  at  the  nape  of  the  neck  is  an  annoying  symptom  in  many 
cases. 

CERVICO-BRACHIAL   NEURALGIA. 

Symptoms.  Paroxysmal  paifi  of  a  severe,  boririg,  burning,  or 
tensive  character,  with  setisations  of  numbness  and  weakness  of  the 
arm,  hand,  shoulder,  scapula,  and  mamma,  with  tenderness  along  the 
cervical  plexus.  CEdema  of  the  arm  and  other  parts  along  the  dis- 
tribution of  the  cervical  plexus  occur  if  the  neuralgia  be  of  long  dura- 
tion, the  result  of  nutritive  changes,  the  limb  at  times  becoming  pale, 
the  skin  glossy,  dry,  and  harsh. 

DORSO-INTERCOSTAL   NEURALGIA. 

Symptoms.  Paroxysmal  pain  of  a  sharp,  and  lancinating  char- 
acter, along  the  fifth  and  sixth  intercostal  spaces,  often  associated 
with  the  development  of  herpes,  the  so-called  herpes  zoster,  or 
"  shingles." 

Tenderness  at  the  points  where  the  nerves  emerge  from  the  inter- 
vertebral foramina  at  the  sides  of  the  chest  and  at  points  in  front. 

LUMBO-ABDOMINAL   NEURALGIA. 

Symptoms.  Paroxysmal  pain  of  a  sharp  and  lancinating,  at 
times  heavy  and  dull,  character,  following  the  course  of  the  ilio-hypo- 
gastric  nerve,  ilio-inguinal  and  external  spermatic  nerve,  supplying 
the  integument  of  the  hip,  the  inner  side  of  the  thigh,  the  scrotum 
and  labium. 

SCIATICA. 

Definition.  A  neuritis.  Pain  following  the  course  of  the  sciatic 
nerve.  The  sacral  plexus  is  made  up  of  the  fourth  and  fifth  lumbar 
and  the  first  two  pairs  of  sacral  nerves. 


DISEASBS    OF   THE   NERVES.  481 

Symptoms.  Sciatica  usually  follows  an  attack  of  lumbago,  the 
pain  becoming  fixed  in  the  sciatic  nerve  ;  at  times  it  is  a  true  neuritis. 

The  pain  is  sharp,  tearing,  shooting,  or  lancinating  in  character, 
increased  upon  motion,  shooting  along  the  course  of  the  nerve  into 
the  hip,  inner  side  of  the  thigh,  calf  of  the  leg,  ankle,  and  heel,  at 
one  or  all  of  these  points,  in  paroxysms  lasting  from  a  few  hours  to 
twenty-four  hours  or  longer.  The  tactile  sensation  in  the  foot  and 
motility  in  the  limbs  are  impaired,  and  if  of  long  duration,  wasting 
of  the  limb  occurs. 

ERYTHROMELALGIA. 

Synonyms.     "  Red  neuralgia." 

Symptoms.  This  form  of  neuralgia  was  first  described  by  Dr. 
S.  Weir  Mitchell.  The/^.?/  principally,  are  affected  by  intense  redness 
and  burnijig pain.  For  a  considerable  period  before  the  condition 
is  typically  developed  there  are  aching  pains  in  the  feet,  particularly 
when  used.  The  feet,  in  Dr.  Mitchell's  own  words,  "  get  redder  and 
redder,  the  veins  stand  out  in  a  few  minutes  as  if  a  ligature  had  been 
tied  about  the  limb,  and  the  arteries  throb  violently  for  a  time,  until 
at  length  the  extremities  become  of  a  dark  purplish  tint."  As  a  rule, 
the  redness  only  occurs  when  the  feet  hang  down,  and  when  at  rest 
they  may  be  pale  and  perspire  freely.  Blisters  and  ulcers  follow 
slight  contusions  of  the  feet. 

Diagnosis.  Erythromelalgia  has  been  confounded  with  Ray- 
naud's disease.  The  presence  of  pain,  bright  redness,  throbbing,  and 
increased  temperature  of  the  part  are  all  the  opposite  of  Raynaud's 
disease. 

PROGNOSIS   OF   NEURALGIAS. 

If  promptly  and  properly  treated,  unless  the  result  of  pressure  of 
an  exostosis,  aneurism,  or  other  tumor,  favorable,  save  for  erythro- 
melalgia. 

TREATMENT. 

Rest;  easily  assimilated  but  nutritious  diet;  removal  of  the  cause, 
if  possible.  If  ^.n^rmc,  ferricm  and  arsenicum.  If  rheumatic,  alka- 
lies and  sodii  salicylas.  If  syphilitic  or  the  result  of  metallic  poisons, 
potassii  iodidu7n.     If  malarial,  quinincB  sulphas,  or  hydrochloras. 

For  an  attack,  tnorphince  sulphas  and  atropines  sulphas,  hypoder- 
mically,  afford  the  most  prompt  and  ready  relief. 

Success  usually  follows  the  use  of  the  well-known  "  Gross  (Prof.  S. 
D.)  neuralgic  pill  "  : 

ai 


482  PRACTICE    OF    MEDICINE. 


.     Quinina.*  sulphat., gr.  ij 

.13    Gm 

Morphinne  sulphat gr.  ^'^ 

.003  Gm 

Strychninre  sulphat.,      •    •    •    •    gr-  7V 

.002  Gm 

Acidi  arseniosi, g""-  uV 

.003  Gm 

Extract!  aconiti, gr.  ^ 

.032  Gm 

Ft.  pil.  No  j. 

SiG. — One  every  one,  two,  or  three  hours. 

Few  attacks  of  trigeminal  neuralgia  will  resist  the  following  powerful 
prescription  : 

R .     Aconitinse  (Duquesnel),     .  .    .    gr.  ^'5  .006  Gm. 

Glycerini, 

Alcoholis, ^'T-foJ  ^^     4-         Cc. 

Aqucc  menth.  pip.,  ....      adf^^ij  ad  60.         Cc. 

SiG. — Teaspoonful,  repeated  from  four  to  eight  times  daily,  carefully 
watching. 

For  the  pains  of  intercostal  neuralgia,  the  following  is  recom- 
mended : 

R.     Chloral, 3J  4-  Gm. 

Pulv.  camphorre, 3J  4.  Gm. 

Menthol, 3J  4.  Gm. 

Mix  and  rub  together. 

SiG. — Paint  over  painful  parts  with  brush,  p.  r.  n. 

Facial  neuralgia  is  often  wonderfully  benefited  by  the  internal 
administration  of  extractum  gelscmii  Jluidum,  n\,iij-v  (0.2-0.3  Cc), 
every  three  or  four  hours  until  its  physiological  effects  are  produced; 
cannabis  indica  or  belladonna  may  be  combined  with  the  gelsemium. 
Excellent  results  often  follow  the  administration  of  Moussette" s  pills 
(aconitine  and  quinine). 

For  sciatica,  antipyrin,  gr.  xx  (1.3  Gm.),  repeated  two  or  three  times 
daily,  has  given  relief,  as  hssplienacetiti  and  a7itifebrin.  The  deep  injec- 
tion of  chloroformtan  is  recommended  by  Bartholow.  Nitroglycer- 
inum  has  been  strongly  recommended  for  sciatica,  beginning  with  one 
drop  of  a  one  per  centum  solution  three  or  four  times  a  day  and  gradu- 
ally increasing  the  dose  until  four  or  five  drops  several  times  daily 
are  taken.  Dr.  Mitchell  is  a  strong  advocate  of  the  application  of  a 
flannel  bandage  for  the  entire  leg,  changed  daily,  and  a  splint  reach- 
ing from  the  axilla  to  the  heel,  held  loosely  to  the  limb,  and  tonics. 
Rarely,  he  uses  cocaiitCB  hydrochloras  gr.  \  (0.016  Gm.)  hypodermically 
over  a  painful  spot.     A  spray  of  chloride  of  methyl  along  the  course 


DISEASES  OF   THE   NERVES,  483 

of  the  nerve  for  a  few  moments,  watching  the  skin,  will  relieve  the 
distressing  pain.  Rarely,  full  doses  of  potassii  iodidum  with  a  blister 
along  the  course  of  the  nerve  gives  relief. 

For  erythromelalgia  all  drug  treatment  has  failed  to  cure.  Rest 
and  elevation  of  the  limb  gives  rehef.  Dr,  Mitchell  recommends 
either  nerve  stretching,  and  in  aggravated  cases  nerve  excision. 

All  forms  of  neuralgia  are  more  or  less  benefited  with — 

^.      Quininse  sulph., gr-  iij  -2  Gm. 

Ferri  reduct, gr.  j  .065       Gm. 

Acid,  arseniosi, g^-  2V  -^^S      ^™* 

Aconitise, gr.  yi^  .00054  Gm, 

In  pill,  every  four  or  five  hours. 


FACIAL  PARALYSIS. 

Synonjmi,     Bell's  palsy. 

Definition.  An  acute  paralysis  of  the  seventh  cranial, — the  facial 
nerve,  the  great  motor  nerve  of  the  muscles  of  the  face, — the  nerve 
of  expression. 

Causes,  Exposure  to  a  current  of  cold  air  against  the  side  of  the 
face — over  the  pes  anserinus — is  the  most  frequent  cause.  Also  due 
to  injury  or  disease  of  the  middle  ear.     Syphilis, 

Symptoms.  The  facial  nerve  supplies  the  muscles  of  the  face, 
the  muscles  of  the  external  ear,  also  the  stylo-hyoid,  posterior  belly  of 
the  digastric,  the  platysma,  one  muscle  of  the  middle  ear,  the  stape- 
dius, and  one  palate  muscle,  the  levator  palati ;  by  means  of  the 
chorda  tympani  branch  it  controls  the  secretion  of  the  parotid  and 
submaxillary  glands,  and,  possibly,  the  sense  of  taste.  It  also 
furnishes  motor  power  to  the  azygos  uvulae,  the  tensor  tympani,  and 
the  tensor  palati  muscles. 

The  onset  is  usually  sudden,  with  tingling  of  the  lips  and  tongue, 
and  upon  looking  into  the  mirror  the  patient  is  surprised  by  the  per- 
fectly blank,  motionless  side  of  his  face  ;  the  corner  of  the  mouth  is 
depressed,  the  eyelids  open,  the  face  drawn  toward  the  well  side,  and 
the  patient  is  unable  to  expectorate,  whistle,  or  swallow. 

Any  of  the  muscles  innervated  by  the  nerve  may  participate  in  the 
paresis. 

The  electro-contractility  is  feeble  or  lost.     The  reflexes  are  abolished. 


484  PRACTICE    OF    MEDICINE. 

Diagnosis.  Paralysis  of  the  muscles  of  the  face  occurs  in  hemi- 
plegia ;  the  points  of  ditTerentiation  are  the  presence  of  cerebral 
symptoms  and  the  normal  reflex  excitability. 

Facial  palsy  with  otorrhcea, '  imperfect  hearing,  obliquity  of  the 
uvula,  and  loss  of  taste  determine  its  origin  within  the  aqua;ductus 
Fallopii. 

It  is  due  to  peripheral  neuritis  if  the  taste  be  normal  and  the  uvula 
straight. 

If  other  nerves  are  also  involved,  the  origin  is  central. 

Prognosis.     Favorable. 

Treatment.  If  the  result  of  cold  and  damp,  diaphoresis  with 
pilocarpus,  or  diuresis  with  potatsii  acetas,  vel  iodidum,  and  blisters 
in  front  of  the  ear,  and  the  use  of  galvanism  to  the  affected  muscles. 


GENERAL  OR  NUTRITIONAL  DISEASES. 


CHOREA. 


Synonyms.     St.  Vitus'  dance;  insanity  of  the  muscles. 

Definition.  A  functional  (?)  disorder  of  the  nervous  system; 
characterized  by  irregular  spasmodic  fibrillary  movements  of  groups 
of  muscles,  with  muscular  weakness,  more  or  less  approaching  paral- 
ysis of  the  affected  parts. 

Causes.  Essentially  a  disease  of  childhood  ;  hereditary  ;  reflex, 
from  dentition,  worms,  masturbation,  or  fright;  probably  the  result 
of  rheumatism  in  many  cases. 

Pathological  Anatomy.  As  yet  there  has  been  no  constant 
anatomical  lesion  discovered,  the  theory  of  emboli  having,  however, 
many  advocates. 

Symptoms.  The  onset  is  usually  gradual,  the  child  seemingly 
grimacing  or  jerking  the  arm  or  hand,  as  if  in  imitation,  followed  soon 
by  decided  irregular  jactitations  of  the  muscles  of  the  face  (histrionic 
spasm),  of  the  eyelids  (blepharospasm),  eyeballs  (nystagmus),  and 
the  shoulder,  arm,  and  hand,  finally  extending  to  the  lower  extremi- 


GENERAL   OR   NUTRITIONAL  DISEASES.  485 

ties,  interfering  with  motility;  in  severe  cases,  inability  of  self-feeding 
or  of  holding  anything  in  the  hands.  The  speech  is  often  unintelli- 
gible, the  tongue  constantly  moving  in  an  irregular  manner. 

The  heart's  action  is  tumultuous  and  irregular,  associated  often  with 
a  soft,  blowing,  systolic  murmur,  most  distinct  at  the  base.  The 
muscles  are  usually  quiet  during  sleep,  although  this  is  not  always 
the  case.  The  mind  is  somewhat  blunted,  the  temper  irritable,  the 
memory  impaired.  If  the  irregular  muscular  movements  are  con- 
fined to  one  side  of  the  body,  it  is  termed  hemi-chorea. 

Diagnosis.  Chorea  was  confounded  with  epilepsy  until  the  points 
of  distinction  were  pointed  out  by  Sydenham. 

Huntington's  or  chronic  chorea  is  distinctly  hereditary,  and,  instead 
of  being  fibrillary  contraction  of  muscles,  involves  whole  groups  of 
muscles,  so  that  the  patient  seems  to  be  posturing  and  grimacing, 
with  a  dancing  movement,  with  many  queer  contortions  of  the  face 
and  head.  Generally,  all  the  muscles  of  the  body  are  involved.  It 
may  have  associated  the  fibrillary  muscular  contractions  of  St.  Vitus' 
dance. 

^  Paralysis  agitans  has  general  muscular  tremor,  beginning  in  one 
limb,  gradually  progressing,  uninfluencea  by  treatment;  a  disease  of 
the  elderly. 

Post-hemipiegic  chorea  is  the  choreic  movement  of  a  paralyzed 
limb. 

Prognosis.  The  vast  majority  of  cases  recover,  but  relapses  are 
very  frequent. 

Treatment.  Remove  the  cause,  if  possible.  Easily  assimilated 
diet.  Many  cases  improve  rapidly  by  confinement  to  bed  in  a  dark- 
ened room.  If  the  muscular  movements  interfere  with  sleep,  mor- 
phiftcs  sulphas  or  chloral Sixe  indicated.     Regulate  the  secretiorls. 

Arsenicum  is  the  most  reliable  remedy  yet  introduced  for  the  treat- 
ment of  chorea.  It  should  be  pushed  to  its  first  physiological  effects, 
then  gradually  reducing  the  dose  until  all  symptoms  disappear.  The 
form  of  the  remedy  best  adapted  for  administration  in  this  disease  is 
liquor  potassii  arsenitis,  Ti\,v  (0.3  Cc).  increased  to  in^x  (0.6  Cc),  or 
even  n^xv  (i  Cc),  three  times  a  day.  Exiractu7n  cimicifugczfluidum, 
lTLxx-f3j  (1.3-4  Cc),  t.  d.,  is  serviceable,  especially  in  cases  following  a 
rheumatic  attack.  Cases  resisting  the  arsenicum  treatment  may  rapidly 
improve  under  hyoscyaniinincs  hydrobro7nas,  gr.  -j^-i^^  (0.00032- 
0.00065  Gm.),  three  times  daily.     A  patient  of  mine,  aged  sixteen 


486  PRACTICE    OF    MEDICINE. 

years,  who  resisted  all  the  remedies  mentioned,  was  promptly  cured  by 
antipyrin,  gr.  x  (0.6  Gm.),  four  times  daily.  This  same  lad  had  a 
former  attack  arrested  by  viorphince  sulphas,  gr.  %  (0.016  Gm.),  four 
limes  daily,  but  this  latter  remedy  failed  in  the  attack  controlled  by 
the  antipyrin.  If  anaemia  be  present,  combine  or  alternate  arsenkum 
w'\th /errum.     Wood  recommends  quinina  sulphas. 


EPILEPSY. 

Definition.  A  chronic  disease,  of  which  the  characteristic  symp- 
toms are  a  sudden  loss  of  consciousness,  attended  with  more  or  less 
general  convulsions. 

Causes.  True  epilepsy  almost  always  first  arises  during  the  growth 
and  development  of  the  brain.  Heredity.  Rarely,  worry,  anxiety, 
depression,  or  fright.  Pressure  from  a  tumor  at  the  periphery,  or 
thickening  of  the  membranes  of  the  brain  causing  pressure; 
syphilis ;  uterine  diseases. 

Pathological  Anatomy.  There  are  no  constant  anatomical 
lesions,  as  yet,  associated  with  essential  epilepsy. 

In  "  Jacksonian,"  "cortical,"  or  "  partial  epilepsy,"  however,  the 
"motor  cortex"  is  irritated  by  disease  and  there  occur  tonic  and 
clonic  spasms  of  the  same  character  as  in  general  epilepsy,  confined 
to  a  single  arm,  or  an  arm  and  half  the  face  together,  or  may  be  the 
entire  half  of  the  body.  These  epileptiform  attacks  furnish  precise 
data  as  to'  the  locality  of  the  lesion  ;  spasms  affecting  the  distribution 
of  the  facial  nerve  point  to  the  lower  third  of  the  central  convolution  ; 
of  the  arm,  the  middle  third  of  the  central  convolution;  of  the  lower 
extremity,  the  upper  third  of  the  central  convolution. 

Varieties.  I.  Epilepsia  gravior,  le  grand  mal ;  II.  Epilepsia 
mitior,  le  petit  mal. 

Symptoms.  Le  grand  mal  \s  preceded  by  a  more  or  less  pro- 
nounced and  curious  sensation,  the  so-called  aura  epileptica. 

The  attack  proper  is  sudden,  the  subject  suddenly  falling,  with  a 
peculiar  cry,  loss  of  consciousness,  and  pallor  of  the  face,  the  body 
assuming  a  position  of  tetanic  rigidity,  succeeded  after  a  few  mo- 
ments by  more  or  less  pronounced  clonic  convulsions  followed  by 
cotna  of  several  hours'  duration.  The  subject  awakens  with  a  con- 
fused   or    sheepish    expression,   with   no   knowledge   of  what  has 


GENERAL   OR   NUTRITIONAL    DISEASES.  487 

occurred,  unless  he  has  injured  himself  during  the  attack,  either  by 
the  fall,  or,  what  is  very  common,  has  bitten  his  tongue  during  the 
convulsions. 

Le  petit  inal  is  manifested  either  by  attacks  of  vertigo,  the  con- 
sciousness being  preserved,  or  by  2.  passing  absent-mindedness,  either 
form  being  associated  with  slight  convulsive  phenomena  followed  by 
slight  coma  or  mental  confusion  of  short  duration. 

The  mental  functions  are  not,  as  a  rule,  injured  by  attacks  of  epi- 
lepsy, unless  they  recur  very  frequently.  Indeed,  when  at  wide 
intervals,  the  subject  seems  relieved  by  them,  "  the  sudden,  excessive, 
and  rapid  discharge  of  gray  matter  of  some  part  of  the  brain  on  the 
muscles,"  the  so-called  "  electrical  storm,"  having  cleared  the  cere- 
bral atmosphere. 

The  great  majority  of  epileptics  suffer  from  chronic  gastric  catarrh, 
and  have  at  the  same  time  an  inordinate  appetite  (boulimia) ;  indeed, 
an  attack  of  gluttony  may  immediately  precede  a  fit. 

Epileptics  are  very  liable  to  the  development  of  tuberculosis  and 
of  nephritis. 

Diagnosis,  Uremic  convulsions  closely  resemble  an  epileptic 
attack  ;  but  the  dropsy  or  general  oedema  and  albuminous  urine, 
and  increased  temperature  of  the  former  should  guard  against  error. 

Feigned  epilepsy  often  misleads  the  most  practical  expert. 

Jacksonian  epilepsy  begins  as  a  spasm  of  a  limb  or  some  portion 
of  a  limb,  and  is  confined  there  or  may  gradually  extend  until  even  a 
general  convulsion  occurs. 

Prognosis.  The  vast  majority  of  cases  will  not  recover  under 
treatment,  but  have  the  frequency  and  severity  of  the  attacks  greatly 
ameliorated,  but  sooner  or  later  returning  with  their  former  severity. 
Cases  the  result  of  the  various  reflex  causes  usually  recover  when  the 
cause  is  removed. 

Treatment.  To  avert  an  impending  attack,  inhalations  of  amyl 
nitris,  Ti\,iij-v  (0.2-0.3  Cc),  a  few  whiffs  of  chlorofortnum,  or  the  hypo- 
dermic injection  oi  morphincB  sulphas. 

To  prevent  the  return  of  attacks,  remove  the  causeif  possible,  and 
attention  to  the  secretions  and  the  internal  administration  oi  potassii 
bromidum,  in  doses  sufficient  to  abolish  the  faucial  reflex  and  produce 
the  symptoms  of  bromism,  have  great  power  in  diminishing  the 
severity  and  frequency  of  the  attacks ;  better  results  are  sometimes 
obtained  by  the  combination  of  the  various  bromides.     Cases  in  which 


488  PRACTICE    OF    MEDICINE. 

the  bromides  are  not  serviceable  are  sometimes  benefited  by  ar^e/ni 
niiras,  belladonna,  or  cannabis  indica,  but  such  cases  are  rare. 
Weak  and  an;vmic  subjects  usually  do  better  with  strychnina  in  full 
doses  than  with  potassii  bromidum.  If  a  history  of  syphilis  can  be 
obtained,  the  combination  oi potassii  iodidum  zxi^  potassii  bromidum, 
will  effect  a  cure. 

Whichever  of  the  above  remedies  is  beneficial  in  any  particular 
case,  the  permanency  of  the  relief  can  only  be  maintained  by  the  con- 
tinuation of  the  drug  for  at  least  two  years  after  the  last  attack. 

Gowers  highly  recommends  the  following  in  cases  complicated 
with  cardiac  dilatation  : 

R.     Potassii  bromidi, gr- xx  Ii3  Gm. 

Tinct.  digitalis, tt\^x  .6  Cc. 

SiG. — Tiiree  times  a  day,  well  diluted. 

The  following  is  the  combination  used  in  the  insane  wards  of  the 
Philadelphia  Hospital : 

R.     Sodii  bromidi, 

Potassii  bromidi, aa    ^iv              aa  l6.  Gm. 

Liq.  potassii  arsenitis, f^iss   .  6.  Cc. 

Aqux  mentha;  pip., f.^iij  QO-  Cc. 

Inf.  gentian,  comp.,    .    q.  s.   ad  f.^viij            ad  240.  Cc. 
SiG. — Tablespoonful,  diluted,  three  times  daily. 

Brown-Sequard's  mixture  for  epilepsy  is  as  follows  : 

R.     Potassii  iodidi 8  parts. 

Potassii  bromidi, 8     " 

Ammonii  Ijromidi, 4     " 

Potassii  bicarlj., 5     " 

Inf.  columbo, 360     " 

SiG. — One  teaspoonful  before  meals,  and  three  dessertspoonfuls  on  going  to 

bed. 

The  following  is  an  effective  combination  for  the  "  mixed  bro- 
mides" : 

R.     Sodii  bromidi, Jj  30.  Gm. 

Potassii  bromidi, ^  vss  22.  Gm. 

Ammonii  bromidi, .^'^'i'j  10.6  Gm. 

Potassii  bicarb., ;^  ij  8.  Gm. 

Inf.  columbo,      f ,^  x  300.  Cc. 

Aq.  chloroformi,     .    .    q.  s.  ad    Oj  ad  480.  Cc.  M. 

SiG. — Tablespoonful  equals  gr.  xxx  (2  Gm.). 


GENERAL   OR    NUTRITIONAL   DISEASES.  489 

Status  epileptictis  is  always  a  dangerous  condition,  and  efforts  to 
prevent  it  should  be  made  by  active  medication  the  moment  a  series 
or  group  of  fits  occur.  The  following  combinations  sometimes  are 
wonderfully  successful  in  aborting  the  status  : 

U .     Chloral, gr.  xxx  2.  Gm. 

Tinct.   cannab.  indicse,  ....   TTLxv  I.  Cc. 

Infus.  digitalis, fgj  30.  Cc.  M. 

SiG. — By  high  enema,  repeated  if  indicated  in  two  or  three  hours. 

Dr.  Spratling,  Craig  Epileptic  Colony,  recommends: 

R.      Tinct.  opii  deodorat.,     ....    TTLv  .3     Cc. 

Potassii  bromidi, gr.  xxx  2.       Gm. 

Chloral, g*"-  '^x  1-3    Gm. 

Liq  morph.  (U.  S.), ■n\^iss  .09  Cc. 

Aquse, f^ss  15.      Cc.  M. 

SiG. — By  mouth,  or,  if  cannot  swallow,  by  enema. 

A  hypodermic  injection  of  morphince  sulphas,  gr.  ^  (0.02  Gm.), 
and  atropincE  sulphas,  gr.  -^-^  (0.00 1  Gm.),  has  sometimes  broken  up  a 
series  of  epileptic  spasms. 

The  diet  of  the  epileptic  must  be  carefully  regulated — meats,  tea, 
and  coffee  excluded,  or  used  in  ve^y  moderate  amounts.  Forbid 
tobacco  and  alcohol. 

Much  enthusiasm  is  reported  in  the  important  results  following  tre- 
phining in  cases  of  Jacksonian  epilepsy.  It  is  to  be  hoped  success 
will  follow  this  operation,  but  the  subject  is  still  sub  judice. 

"  The  surgical  treatment  of  epilepsy  has  been  extensively  employed, 
but  it  is  distinctly  disappointing,  for,  while  almost  any  operation  may 
benefit  a  patient  for  a  time,  there  is  no  operation  which  will  certainly 
cure  "  (J.  Chalmers  Da  Costa). 


HYSTERIA. 

Definition.  A  nutritional  disorder  of  the  nervous  system,  of  the 
nature  of  which  it  is  impossible  to  speak  definitely  ;  characterized  by 
disturbances  of  the  will,  reason,  imagination,  and  the  emotions,  as 
well  as  motor  and  sensory  disturbances. 

Causes.  A  morbid  condition  confined  principally  to  women. 
Young  girls,  old  maids,  widows,  and  childless  married  women  are 
the  most  frequent  subjects  of  the  disorder.    The  paroxysms  frequently 


400  PRACTICE    OF    MEDICINE. 

develop  during  the  menstrual  epoch.  The  menopause  is  another 
frequent  period  for  its  manifestation.  A  peculiar  condition  of  the 
nervous  system,  either  inherited  or  acquired,  is  responsible  for  the 
phenomena  of  hysteria,  the  peculiar  manifestations  being  excited  by 
disturbances  of  either  the  sexual,  digestive,  circulatory,  or  nervous 
systems. 

Hypochondriasis,  a  peculiar  mental  condition,  characterized  by 
inordinate  attention  on  the  part  of  the  patient  to  some  real  or  sup- 
posed bodily  ailment  or  sensation.  A  continual  introspection,  as 
seen  in  males,  is  a  condition  much  like  the  hysteria  of  the  female. 

Pathogeny.  Structural  alterations  having  thus  far  not  been  de- 
tected in  cases  of  hysteria,  it  is  classed  as  a  functional  disturbance  of 
the  nervous  system.  It  should,  however,  be  borne  in  mind  that 
hysterical  manifestations  frequently  develop  during  the  prevalence 
of  organic  diseases. 

Symptoms.  These  will  be  considered  under  the  headings  of  the 
hysterical  paroxysm,  and  the  hysterical  state . 

The  Hysterical  Paroxysm  or  fit  occurs  nearly  always  in  the  pres- 
ence of  others,  and  develops  gradually  with  sighing,  meaningless 
laughter,  causeless  moaning,  nonsensical  talking,  and  gesticulations, 
or  a  condition  oi fidgets  followed  with  a  sensation  oi choking,  dyspnoea, 
and  a  ball  in  the  throat — i\\e  globus  hystericus.  These  and  similar 
symptoms  precede  the  fit,  during  which  the  unconsciousness  is  only 
apparent,  the  patient  being  aware  of  what  is  transpiring  about  her. 
During  the  paroxysm  the  patients  may  struggle  violently,  throwing 
themselves  about,  their  thumbs  turned  in  and  their  hands  clenched. 
Again,  spasmodic  movements  occur,  varying  from  slight  twitching  in 
the  limbs  to  powerful  general  convulsive  movements,  and  to  almost 
tetanic  spasms. 

The  paroxysm  ends  by  sighing,  laughing,  crying,  and  yawning, 
and  a  sensation  of  exhaustion.  During  the  attack  it  will  be  noted 
that  the  surface  and  face  are  normal,  showing  absence  of  respiratory 
embarrassment,  the  breathing  varying  from  very  quiet  to  spluttering 
and  gurgling  sounds,  the  pupils  not  dilated,  the  pulse  normal,  the 
temperature  normal,  and  absence  of  foaming  at  the  mouth  and 
wounding  of  the  tongue. 

The  Hysterical  State  is  shown  by  disturbances  of  the  mental  and 
sensory -tnotor  inviC\\ox\s  respectively.  It  may  be  a  permanent  condi- 
tion or  occur  at  intervals  with  <;reater  or  less  severity. 


GENERAL   OR   NUTRITIONAL   DISEASES.  491 

Mental  disturbances.  The  patients  are  emotional,  erratic,  excitable, 
impatient,  and  self-important,  showing  marked  defects  of  will  and 
mental  power. 

Sensory  disturbances.  This  is  either  a  condition  of  exaggerated 
sensibility  or  hyperaesthesia,  as  shown  by  the  marked  effects  from  the 
slightest  irritation  and  the  cutaneous  tenderness  along  the  spine,  or  a 
condition  of  anaesthesia,  as  shown  by  the  apparent  absence  or  recogni- 
tion of  pain  after  severe  irritation,  or  a  perverted  sensibility,  as  shown 
by  the  feeling  of  tingling,  numbness,  and  formication.  Sensibility  to 
heat  or  cold  are  often  absent.  There  is  great  perversion  of  the  special 
senses  in  many  of  the  cases. 

Charcot,  referring  to  the  ovarian  hyperaesthesia  of  hysteria,  says : 
"  It  is  indicated  by  pain  in  the  lower  part  of  the  abdomen,  usually 
felt  on  one  side,  especially  the  left,  but  sometimes  on  both,  and  occu- 
pying the  extreme  limits  of  the  hypogastric  region.  It  may  be 
extremely  acute,  the  patient  not  tolerating  the  slightest  touch  ;  but  in 
other  cases  pressure  is  necessary  to  bring  it  out.  The  ovary  may  be 
felt  to  be  tumefied  and  enlarged.  When  the  condition  is  unilateral, 
it  may  be  accompanied  with  hemianassthesia,  paresis,  or  contracture 
on  the  same  side  as  the  ovarialgia ;  if  it  is  bilateral,  these  phenomena 
also  become  bilateral.  Pressure  upon  the  ovary  brings  out  certain 
sensations  which  constitute  the  aura  7iyste7-ica,\>\x\.  firm  and  systematic 
compression  has  frequently  a  decisive  effect  upon  the  hysterical  con- 
vulsive attack,  the  intensity  of  which  it  can  diminish,  and  even  the 
cessation  of  which  it  may  sometimes  determine,  though  it  has  no 
effect  upon  the  permanent  symptoms  of  hysteria." 

Motor  disturbances.  These  phenomena  embrace  every  variety  of 
motor  disturbance,  from  exaggerated  excitable  movements  to  defect- 
ive or  complete  loss  of  power.  With  the  paralysis  that  may  occur, 
neither  nutrition  nor  sensation  is  constantly  impaired.  Hysterical 
paralysis  is  liable  to  frequent  and  sudden  changes,  the  loss  of  power 
often  disappearing  suddenly.  Hysterical  contractures  often  are  most 
extensive  and  persistent.  Under  some  emotion  or  unknown  cause  a 
group  or  groups  of  muscles  contract  abruptly  or  by  degrees,  the 
spasms  involving  flexors  or  extensors  or  both  with  changes  in  reflexes, 
and  lasting  for  days  or  years.  Aphonia,  from  paralysis  of  the  laryn- 
geal muscles,  is  a  frequent  form  of  paresis.  Some  hysterical  patients 
refuse  to  even  make  an  attempt  at  speech  (mutism). 

"A  curious  enlargement  of  the  abdomen  is  observed  sometimes, 


492  PRACTICE   OF    MEDICINE. 

constituting  the  so-called  phixntom  itttnor.  This  region  presents  a 
symmetrical  prominence  in  front,  often  of  large  size,  with  a  constric- 
tion below  the  margin  of  the  thorax  and  above  the  pubes.  The 
enlargement  is  quite  smooth  and  uniform,  soft,  very  mobile  as  a  whole 
from  side  to  side,  resonant,  but  variable  on  percussion,  and  not  pain- 
ful. Vaginal  examination  gives  negative  results,  and  under  chloro- 
form the  prominence  immediately  subsides,  returning  again  as  the 
patient  regains  consciousness. 

Among  the  numerous  other  symptoms  that  may  develop  in  a  hys- 
terical patient  are  disturbances  of  digestion,  circulation,  respiration, 
and  disorders  of  micturition  and  menstruation. 

Among  other  phenomena  that  belong  to  the  Hysterical  State  are 
to  be  mentioned  Hystero-epilcpsy,  a  condition  of  hysteria  to  which  is 
superadded  the  convulsion,  epileptic  in  form.  Catalepsy,  a  condition 
in  which  the  will  seems  to  be  cut  off  from  certain  muscles,  and  in 
whatever  position  the  affected  member  is  placed,  it  will  so  remain  for 
an  indefinite  time.  There  may  or  may  not  be  unconsciousness  and 
loss  of  sensation.  Trance,  the  individual  lying  as  if  dead,  circulation 
and  respiration  having  almost  ceased.  Ecstasy,  a  condition  in  which 
the  individual  pretends  to  see  visions,  and  acts  in  a  most  ridiculous 
manner. 

Diagnosis.  The  hysterical  state  is  so  general  in  its  manifesta- 
tions that  it  is  to  be  borne  in  mind  in  diagnosing  all  ailments  occurring 
in  women.  The  diagnosis  is  attended  with  great  difficulty,  however,  and 
requires  the  display  of  all  the  skill  of  the  clinician  to  prevent  error. 

Prognosis.  Death  from  either  a  hysterical  fit  or  the  hysterical 
state  is  the  rarest  of  events,  if  it  ever  occur.  The  ultimate  recovery 
of  a  hysterical  patient  is  of  frequent  occurrence.  Marriage  has  cured 
many  cases,  although  it  can  hardly  be  advised  by  the  physician. 

Treatment.  For  the  hysterical  fit  little  need  be  done,  as  a  rule, 
unless  the  paroxysm  is  violent  or  prolonged,  in  which  case  ammonii 
valerianas,  Hoffman  s  anodyne,  or  spiritus  am))ionicE  aromatictts,  may 
be  administered.  Charcot  recommends  the  making  of  firm  pressure 
over  the  ovarian  region  to  check  hysterical  fits  that  are  of  a  severe 
character. 

The  management  of  a  confirmed  case  of  hysteria  will  tax  the  skill 
of  the  most  astute  physician.  It  is  in  connection  with  hysteria  that 
the  peculiar  phenomena  supposed  to  arise  from  applying  different 
metals  to  the  surface  of  the  body  have  been  noticed. 


GENERAL   OR   NUTRITIONAL   DISEASES.  493 

Moral  and  hygienic  measures  are  of  the  first  importance  in  the 
management  of  hysterical  patients.  The  treatment  by  isolation  of 
hysterical  patients  is  strongly  urged  by  many  specialists.  Dr.  S. 
Weir  Mitchell  has  devised  a  plan  for  bedfast  hysterical  patients,  of 
massage,  faradization,  and  forced  feeding,  which  has  been  successful 
in  a  number  of  cases. 

There  is  no  fixed  therapeutical  treatment  for  hysteria,  the  various 
symptoms  calling  for  interference  as  they  arise.  It  is  well,  however, 
to  avoid  the  use  of  stimulants,  opiates,  chloral,  and  other  nervous 
sedatives. 


NEURASTHENIA. 

Synonyms.  Spinal  irritation  ;  nervous  prostration  ;  nervous  ex- 
haustion. 

Definition.  A  debility  of  the  nervous  system,  causing  an  inability 
or  lessened  desire  to  perform  or  attend  to  the  various  duties  or  occu- 
pations of  the  individual. 

Prof.  Bartholow  describes  it  as  consisting  "  essentially  in  an  exag- 
gerated susceptibility  to  bodily  impressions  and  false  reasoning 
thereon." 

Causes.  Heredity.  It  may  result  from  various  chronic  diseases ; 
mental  worry  or  emotion  ;  overwork,  as  "  whenever  the  expenditure 
of  nerve-force  is  greater  than  the  daily  income,  physical  bankruptcy 
sooner  or  later  results  "  (Jackson).  Neurotic  temperament ;  sexual 
excesses;  alcohol;  tobacco. 

Symptoms.  Nervous  debility  may  affect  any  organ  of  the  body. 
It  is  a  condition  of  nerve-tire  or  exhaustion,  and  hence  the  nervous 
energy  necessary  for  functional  activity  of  any  particular  organ  may 
be  wanting,  a  fair  example  being  seen  in  cases  of  nervous  dyspepsia. 

One  of  the  earliest  manifestations  of  nervous  exhaustion  is  an  irri- 
tability or  weakness  of  the  mental  faculties,  as  shown  by  inability  to 
concentrate  the  thoughts,  and  efforts  to  do  so  causing  headache,  ver- 
tigo, restlessness,  fear,  a  feeling  of  weariness  and  depression,  together 
with  the  army  of  symptoms  attendant  on  nervousness. 

There  may  be  ocular  disturbances,  cardiac  palpitation,  coldness 
of  the  hands  and  feet,  chilliness  followed  by  flashes  of  heat,  followed 
in  turn  by  slight  sweating.  Patients  are  troubled  with  insomnia,  or 
fatiguing  sleep,  accompanied  with  unpleasant  dreams. 


494  rRACTicR  OF  medicine. 

In  the  male  there  are  genito  urinary  disorders,  with  pains  in  the 
back,  giving  the  dread  of  impotence.  In  females,  painful  menstrua- 
tion, ovarian  irritation,  and  irritable  uterus. 

The  "neurasthenic  stigmata"  are  :  Feeling  of  pressure  on  head; 
disturbance  of  sleep;  pain  in  back;  muscular  weakness;  dyspepsia; 
sexr..\l  disturbances  and  mental  disturbances. 

Diagnosis.  It  is  of  importance  to  determine  between  a  true  ner- 
vous exhaustion  and  nervous  debility  the  result  of  organic  disease. 
A  study  of  the  history  of  the  case,  together  with  the  symptoms,  should 
prevent  error. 

Neurasthenic  symptoms  in  puberty  are  strongly  indicative  of  mental 
instability,  and  great  care  must  be  exercised  to  prevent  actual  insanity 
from  developing. 

Prognosis.  Usually  some  mental  weakness  remains  after  re- 
covery from  an  attack  of  neurasthenia. 

Treatment.  The  physician  should  remember  that  neurasthenia 
is  not  a  disease  per  se,  but  that  the  victim  is  a  sick  individual  needing 
the  best  environment,  rest,  and  good  food.  Attention  to  the  secretions, 
diet,  and  surroundings.  Rest  and  diversion  of  the  mind  are  essential 
to  success.  Travel,  short  of  fatigue,  pleasant  companionship,  and 
relief  from  responsibility.  Bathing,  massage,  and  galvanism  are  im- 
portant aids  in  the  management. 

Among  the  internal  remedies  that  are  of  value  may  be  mentioned, 
arseniciim,  sfrychntna,  ferrum,  zinci  valerianas,  phosphorus,  ex- 
tractum  cocce  fluidum,  vitiutn  cocce,  and  syrupus  hypophosphitis 
covipositits.  QuinincE  sulphas,  in  small  doses,  gr.  i-ij  (0.065-0.13 
Gm.),  daily,  for  weeks,  seems  to  lessen  the  excitability  of  the  nervous 
system. 

The  following  is  an  excellent  neurasthenic  tonic : 

li .     Acid,  phosphoric,  dil., f^;!]  8.   Co. 

Ext.  cocffi  fid., f^^j  24.  Co.  • 

Tinct.  nucis  vomicae, f  .^  'j  8.  Co. 

Syr.  zingiberis, f  .^  '■''S  45-   Cc. 

Aquar  menthce  pip.,    .    ...    ad    f.^vj  ad       180.   Co.  M. 

SiG. — Tablespoonful  after  meals,  in  water. 


GENERAL   OR   NUTRITIONAL   DISEASES.  495 


EXOPHTHALMIC  GOITRE. 

Synonyms.     Graves'  disease ;  Basedow's  disease. 

Definition.  A  disease  of  the  nervous  system ;  characterized  by 
protrusion  of  the  eyeballs,  enlargement  of  the  thyroid  gland,  dilata- 
tion of  the  arteries,  and  palpitation  of  the  heart. 

Causes.  An  undemonstrable  condition  of  the  nervous  system, 
either  inherited  or  acquired,  is  the  predisposing  cause  of  Graves' 
disease.  Among  the  exciting  causes  are  anaemia,  shock,  fright, 
chagrin,  worry,  and  reverses  of  fortune. 

It  is  more  frequent  in  women  than  in  men. 

Pathological  Anatomy.  "  Some  structural  alterations  have 
been  found,  in  a  majority  of  cases,  in  the  sympathetic  ganglia,  and 
especially  in  the  inferior  ganglia."  (Bartholow.)  The  veins  and 
arteries  of  the  thyroid  gland  are  dilated,  the  result  of  a  vasomotor 
paralysis.  The  enlargement  of  the  gland  is  the  result  of  the  dilated 
vessels,  and  a  serous  infiltration  of  its  tissues,  followed,  if  long  con- 
tinued, by  hypertrophy.  A  considerable  increase  of  fat  behind  the 
eyeballs  has  been  observed.  In  the  majority  of  cases  more  or  less 
ansemia  exists. 

Symptoms.  The  development  of  the  quarternary  of  symptoms 
may  occur  suddenly,  the  result  of  some  great  shock  to  the  nervous 
system,  but  in  the  majority  of  instances  the  symptoms  develop  slowly 
and  insidiously,  with  cardiac  palpitation,  with  paroxysms  of  more 
marked  acceleration,  or  tachycardia,  the  pulse-rate  varying  from  goto 
1 20,  150,  and  rarely  as  high  as  200  beats  per  minute ;  zooxi  pulsations 
of  the  vessels  of  the  neck  and  thyroid  gland  may  be  felt  and  seen. 
The  enlargement  of  the  thyroid  gland — the  goitre — appears  gradually 
after  the  development  of  the  circulatory  disturbances,  although  rarely 
it  may  be  the  first  symptom  observed.  The  goitre  is  elastic,  rather 
soft,  and  has  a  thrill  similar  to  an  aneurism.  The  degree  of  enlarge- 
ment varies  in  different  cases,  and  in  none  ever  attains  a  very  great 
size.  Following  the  development  of  the  goitre  occurs  the  protrusion 
of  the  eyeball, — the  exophthalmos, — which  may  be  confined  to  one 
eye,  but  usually  occurs  in  both.  Prominence  of  the  eyeball  may  be 
the  first  symptom  observed,  but  usually  it  does  not  develop  until  after 
the  appearance  of  the  goitre.  The  degree  of  protrusion  varies  from 
a  slight  staring  expression  to  a  point  so  great  that  the  eyelids  cannot 


496  PKACTICE    OF    MEDICINE, 

cover  the  balls.  Associated  with  the  protrusion  of  the  eyeballs  is 
incoordination  in  the  movements  of  the  eyelids  and  the  eyeball,  the 
sign  of  Graefe,  so  that  when  the  eyes  are  quickly  cast  down,  the  eye- 
lids do  not  follow  them,  the  sclerotic  being  visible  below  the  upper  lid. 
Vision  is  unimpaired.  Conjunctivitis  may  arise,  the  result  of  the  im- 
perfect protection  of  the  protruding  ball  by  the  eyelids. 

Associated  with  the  pathognomonic  symptoms  are  nervousness, 
irritability  of  temper,  headache,  insomnia,  vertigo,  fits  of  despondency, 
aphonia,  and  cough  the  result  of  pressure  of  the  goitre,  disorders  of 
digestion,  increase  of  temperature,  anaemia,  and  loss  of  flesh. 

Diagnosis.  The  fully  developed  disease  presents  no  difficulties 
in  diagnosis,  but  during  its  incipiency,  before  the  characteristic  symp- 
toms have  appeared,  the  disease  may  be  confounded  with  such  condi- 
tions as  cardiac  disease,  neurasthenia,  lithaemia,  malaria,  or  incipient 
phthisis. 

Prognosis.  Recovery  occurs  in  a  fair  number,  but  is  slow 
and  tedious.  The  disorders  of  the  circulation  lead  to  dilated  heart  in 
many  cases,  and  ultimately  death  occurs  from  this  cause.  Relapses 
are  frequent. 

Treatment,  One  of  the  first  injunctions  to  be  placed  on  a  case 
of  exophthalmic  goitre  is  rest,  both  physical  and  mental,  as  well  as 
freedom  from  worry  or  emotional  excitement;  little  progress  will  be 
made  if  this  point  be  neglected.  The  general  nervousness,  restless- 
ness, and  insomnia  will  often  call  for  special  treatment,  when  use  may 
be  made  of  chloral,  potassii  brotnidiim,  siilphonal,  or  trional.  It  is 
better,  however,  not  to  use  this  class  of  drugs  in  a  routine  manner, 
but  for  the  special  indications  only. 

The  chief  indication  next  to  rest  is  the  condition  of  the  circulation. 
To  control  this,  two  remedies  are  of  inestimable  value  ;  they  are 
digitalis  and  strophanthus.  The  results  I  have  seen  from  tinctura 
strophanthus,  Ti^v  (0.3  Cc),  from  three  to  six  times  daily,  have  been 
most  satisfactory.  Dr.  Bartholow  "  has  had  good  effects  from  quinina, 
belladonna,  and  ergotin  in  combination."  I  have  had  complete  and 
quite  rapid  recovery  in  three  pronounced  cases  from  dried  extract  of 
thyroid  gland  in  three  grain  doses  (0.2  Gm.)  twice  and  thrice  daily. 
Always  begin  the  use  of  the  preparations  of  thyroid  gland  with  very 
small  doses,  gradually  increasing  as  required.  Argenii  Jiitras,  gr.  y% 
(o  oo8  Gm.),  after  meals,  is  often  a  valuable  remedy,  alternating  with 
strophanthus  or  digitalis. 


GENERAL   OR   NUTRITIONAL   DISEASES.  497 

The  associated  anaemia  is  to  be  treated  hy  ferrum,  arsenicum,  and 
an  easily  digestible  and  nutritious  diet.  Galvanism  to  the  cervical 
sympathetic  and  pneumogastric  is  an  important  adjuvant  to  the 
medicinal  treatment. 

Surgical  treatment  has  been  strongly  urged  for  the  cure  of  exoph- 
thalmic goitre.  DaCosta  (J.  Chalmers),  after  reviewing  the  literature 
of  such  operations,  concludes  :  "  Treat  most  cases  medically  and  by 
rest;  if  medical  treatment  fails,  consider  the  advisability  of  surgical 
treatment.  Surgical  treatment  is  not  certainly  curative,  and  is  dan- 
gerous." 

TETANY. 

Synonyms.     Tetanilla ;  intermittent  tetanus. 

Definition.  A  succession  of  tonic,  usually  bilateral,  painful  mus- 
cular spasms,  occurring  at  irregular  intervals,  without  loss  of  con- 
sciousness. 

Causes.  Unknown.  Probably  a  special  germ.  It  has  been 
observed  in  those  having  a  family  history  of  nervous  disorders. 

Pathology.  The  disease  is  very  rare  in  America,  and  no  lesion 
has  as  yet  been  determined. 

Symptoms.  Tetany  is  the  occurrence  of  intermittent  spasms  in 
the  muscles  of  the  arms,  hands,  legs,  or  feet,  or,  rarely,  the  face  and 
larynx  (laryngismus  stridulus),  associated  with/az«  or  "cramp." 

The  hands  are  thrown  into  a  position  such  as  they  assume  in  writ- 
ing, or  such  as  is  taken  by  the  hand  of  a  midwife ;  or  the  hand  may 
be  tightly  closed,  or  one  or  more  fingers  may  be  cramped.  The 
elbows  and  shoulders  may  be,  at  times,  affected.  In  the  feet  the  toes 
are  drawn  down  and  the  instep  upward,  like  in  equinus.  The  knees 
may  be  cramped  or  the  legs  extended. 

Any  muscles  may  be  involved.  Trousseau  pointed  out  that  in  those 
suffering  from  tetany,  pressure  upon  the  affected  extremities  at  certain 
points  will  excite  the  spasms. 

The  duration  of  the  spasm  varies  from  a  few  moments  to  several 
hours,  the  intervals  being  from  an  hour  to  a  day  or  more.  A  certain 
periodicity  is  noticed  as  to  the  hour  of  the  day  or  night. 

The  electro-contractility  is  increased,  as  are  also  the  reflexes.  Erb 
first  described  the  peculiar  galvanic  exaltation  found  in  this  disease. 

The  consciousness  is  always  preserved,  although  the  patients  are 
very  nervous. 

32 


498  PRACTICE    OF    MKDICINE. 

Diagnosis.  Tetanus  and  tetany  may  be  confounded,  and  yet 
trismus  is  rare  in  the  latter,  and  always  present  in  the  former. 

Prognosis.     Favorable. 

Treatment.  Attention  to  the  secretions  and  excretions,  and  the 
use  of  potassii  bromiiium,  gr.  xx-xl  (1.3-2.6  Gm.),  well  diluted,  three 
times  daily. 

Gowers  recommends  digitalis  for  nocturnal  tetany — those  painful 
cramps  in  the  calves  in  the  early  morning  hours.  Urethan,  gr.  x 
(0.6  Gm.),  every  three  or  four  hours,  is  highly  spoken  of.  Gray  says  : 
"  Cold  to  the  extremities  and  ice  to  the  spine  have  an  excellent 
effect." 

TETANUS. 

Synonyms.     Lockjaw;  trismus;  cephalic  tetanus. 

Definition.  An  acute  or  subacute  infectious  disease,  characterized 
by  muscular  rigidity,  with  paroxysms  of  tonic  convulsions,  the  mind 
remaining  clear. 

Idiopathic  tetanus  when  no  open  wound  is  discoverable. 

Traumatic  tetanus  when  an  open  wound  is  present. 

Tetanus  neonatorum  when  it  attacks  infants. 

Lockjaw  or  trismus  when  the  jaw  alone  is  involved. 

Cephalic  tetanus  when  the  throat  and  face  are  affected. 

Causes.  The  result  of  a  specific  bacillus,  which  usually  gains 
access  to  the  system  through  an  abrasion. 

Pathological  Anatomy.  In  the  post-mortem  examinations 
which  have  been  made,  no  uniform  morbid  appearance  was  dis- 
covered on  microscopical  examination. 

The  brain,  cord,  lungs,  and  muscles  are  markedly  congested,  and 
show  minute  hemorrhages,  such  as  are  met  with  in  all  cases  of  death 
from  convulsions,  and  which  occur  chiefly  during  the  process  of 
death. 

In  four  post-mortem  examinations  of  cases  dying  from  tetanus  at 
the  Philadelphia  Hospital,  marked  chronic  nephritis  was  observed. 
Probably  the  future  may  show  some  connection  between  nephritis 
and  tetanus,  by  which  the  specific  poison  is  not  eliminated  as  it  might 
be  were  the  kidneys  normal. 

Symptoms.  The  onset  is  rather  sudden,  with  stiffness  0/ (he Jaw, 
neck,  and  tongue,  and  some  difficulty  in  swallowing,  which  increases 


GENERAL  OR   NUTRITIONAL   DISEASES.  499 

in  extent,  the  stiffness  passing  down  the  spinal  muscles  to  the  legs, 
which  are  held  in  a  firm  spasm. 

Gradually  tofiic  spasjns  develop,  which,  involving  the  jaw  muscles, 
cause  "  lockjaw  "  ;  the  face  muscles,  "  risus  sardonicus  "  ;  neck  and 
trunk  muscles,  "opisthotonos"  ;  thesetonicconvulsions  are  associated 
with  intense  pain,  and  the  patient  suffers  the  greatest  distress,  particu- 
larly if  the  chest  muscles  are  involved.  Usually  the  febrile  reaction 
is  slight,  but  in  many  cases  102°  F.to  104°  F.  is  reached,  and  in  some 
instances,  as  death  approaches,  108°  F.  to  110°  F,  may  occur,  rising 
still  higher  after  death.  The  mind  remains  clear  till  carbonic  acid 
poisoning  occurs.  Usually  a  wound,  not  severe,  can  be  found,  the 
symptoms  developing  some  two  weeks  after  its  occurrence. 

The  tonic  spasms  are  developed  by  any  sources  of  irritation,  a 
draught  of  air,  shaking  of  the  bed  or  floor,  suddenly  opening  the  door 
of  the  room,  the  presence  of  a  visitor,  or  attempts  at  speaking  or 
movement. 

Diagnosis.  The  symptoms  are  so  characteristic,  with  the  addi- 
tion of  a  history  of  a  wound,  that  an  error  seems  hardly  probable. 

Tetany.  The  spasms  chiefly  affect  the  extremities,  the  muscles 
being  free  in  the  interval  and  trismus  a  late  or  very  rare  condition. 

Strychnine  poisoning  often  closely  resembles  tetanus,  but  there  is 
no  beginning  trismus  and  more  rapid  development  of  the  symptoms. 
No  history. 

Hydrophobia  does  not  have  trismus,  but  respiratory  spasm,  excited 
by  attempts  at  swallowing,  with  increasing  mental  symptoms. 

Prognosis.     Unfavorable.     The  great  majority  die. 

Treatment.  Rest  and  quiet  in  a  dark  room.  Chloral,  potassii 
bromidum,  chloralamid,  morphincz  sulphas,  a,nd  paraldehyde  are  each 
useful  in  cases,  to  hold  in  check  or  lessen  the  severity  of  the  spasm 
for  a  time.  Inhalations  oi  chlorofortnu7n  will  control  the  spasms,  and 
recoveries  have  been  attributed  to  its  use.  Physostigtna  and  anii- 
pyrin  are  recommended  to  remove  the  spasms. 

Success  has  been  reported  in  a  number  of  cases  from  full  doses, 
very  early  in  the  attack,  of  the  tetanus  serum. 

Success  is  reported  from  acidum  carbolicum,  gr.  iij  (0.2  Gm.)  a  day, 
rapidly  increasing  until  gr.  vj-viij  (o  4-0.5  Gm.)  per  day  is  reached, 
by  the  hypodermic  method,  a  tolerance  to  the  drug  being  noted  in 
tetanus.  Baccelli's  method  of  using  acidum  carbolicum  consists  in  the 
administration,  hypodermically,  of  a  two  per  cent,  solution  of  the 


500  PRACTICE    OF    MEDICINE. 

acid  at  two  or  three  hours'  intervals.     Other  methods  are  to  be  con- 
tinued in  addition  to  the  acid. 

The  nutrition  must  be  maintained  ;  often,  on  account  of  the  stiff- 
ness of  the  masseters,  rectal  alimentation  must  be  resorted  to. 


OCCUPATION  NEUROSES. 

Synonyms.     Professional  neuroses  ;  artisans'  cramp. 

Varieties.  Writers'  cramp  ;  piano-players'  cramp  ;  telegraphists' 
cramp;  violin-players' cramp;  dancers' cramp. 

Definition.  A  group  of  affections  of  the  nervous  system,  charac- 
terized by  the  occurrence  of  spasm  (cramp)  and  pain  in  groups  of 
muscles,  in  consequence  of  overuse  or  frequently-repeated  muscular 
acts. 

Cause.  Undetermined.  It  has  been  noticed  that  many  persons 
suffering  from  occupation  neuroses  have  a  family  history  of  nervous 
affections. 

Sjrmptonis.  The  symptoms  of  any  of  the  varieties  named  gener- 
ally develop  gradually  and  slowly,  by  a  (eehng  of  sfi^ness  in  the  used 
member,  the  part  feels  fatigued  and  heavy,  until  it  is  impossible  to 
use  it,  from  the  occurrence  of  spasmodic  contractions.  Pain  on  using 
the  affected  muscles,  often  associated  with  tremor,  and  in  many  cases 
with  an  ZlCXm^X  paralysis. 

Associated  with  the  loss  of  power  to  follow  the  usual  occupation  is 
nervousness,  mental  worry,  and  often  depression.  There  is  often  the 
sensation  of  prickling  and  numbness  in  the  crippled  member. 

The  electro-contractility  is  preserved  until  the  atrophy  of  non-use 
develops. 

Diagnosis.  Calling  to  mind  the  history  of  the  case  and  its  re- 
sults, in  being  limited  to  one  member,  the  nature  of  the  condition  is 
evident. 

Prognosis.     Often  unfavorable.     Some  recoveries  are  reported. 

Treatment.  Rest  of  the  part  and  mental  quiet,  with  tonics  and 
other  means  to  improve  the  general  nutrition.  Faradism  in  weak 
doses  once  or  twice  weekly  seems  useful.  The  following  combina- 
tion was  of  value  in  one  case  of  writers'  cramp  and  in  a  most 
aggravated  case  of  ballet-dancers'  cramp,  each  affecting  the  left 
limb: 


GENERAL   OR   NUTRITIONAL  DISEASES.  501 

R .      Zinci  phosphidi,     . gr.  ij  .13  Gm. 

Ext.  nucis  vomicae, gr.  x  .6    Gm. 

Fern  albimiinat. , gr.  xxx  2.       Gm. 

Ft.  pil.  No.  xxx. 
SiG. — One  after  meals. 


PARALYSIS  AGITANS. 

S3nion3rms.     Shaking  palsy  ;  Parkinson's  disease. 

Deflnition.  A  nervous  disease  of  unknown  pathology,  charac- 
terized by  tremors,  progressive  loss  of  power  in  the  affected  muscles, 
moderate  rigidity,  with  alterations  in  the  gait,  and  at  times  mental 
changes. 

Cause.  Age  seems  to  be  an  etiological  factor,  most  cases  devel- 
oping after  fifty  years.     Most  frequent  in  women. 

Pathological  Anatomy.  No  characteristic  lesion  yet  deter- 
mined. It  being  a  disease  of  past  middle  life,  there  is  probably  an 
interstitial  hyperplasia  of  some  layer  of  the  cortex,  from  alterations  in 
the  intima  of  the  vessels. 

Symptoms.  The  onset  is  gradual,  the  tremor  beginning  in  one 
of  the  extremities,  oftenest  the  hand  and  forearm.  At  first  it  can 
be  controlled  by  the  will,  for  a  time  at  least,  and  is  suspended  by 
voluntary  movement.  The  disease  gradually  extends  until  an  entire 
side  or  the  upper  or  lower  limbs  are  involved.  The  face  and  head 
rarely  present  tremors,  but  are  not  exempt.  A  peculiar  rigidity  of 
the  affected  muscles  is  characteristic  of  the  advanced  stage.  "At  this 
stage  of  the  disease  the  hands  are  apt  to  assume  the  so-called  bread- 
crumbling  position,  /.  <?.,  the  thumb  and  the  fingers  approximate  and 
move  restlessly  over  one  another,  as  in  the  act  of  crumbling  bread. 
There  is  often  a  tendency  on  the  patient's  part  to  go  forward, — so- 
called  propulsion, — and  this  is  sometimes  so  marked  that  if  the  patient 
is  once  started  in  a  walk  forward,  his  gait  becomes  more  and  more 
rapid,  and  he  cannot  stop  himself"  (Gray).  The  patients  are  usually 
restless  and  annoyed  with  insomnia.  The  general  health  is  fair.  The 
mind  is  generally  retained,  although  melancholia  and  mild  dementia 
have  been  noted  in  a  few  cases. 

Diagnosis.  Disseminated  sclerosis  has  a  trem.or,  but  only  on  vol- 
untary movements — intention  tremor.  There  is  also  scanning  speech 
and  ataxic  gait,  with  mental  enfeeblement,  as  shown  by  an  imnatural 
contentment  with  the  physical  condition  and  surroundings. 


502  PRACTICE    OK    MEDICINE. 

Chorea  is  a  tremor,  but  the  movements  are  general,  and  particu- 
larly involving  the  muscles  of  the  face.  Again,  chorea  is  a  disease 
of  children  and  young  adults. 

Prognosis.  Radical  cure  not  seen.  Improvement  often  results 
from  early  treatment.     The  disease  does  not  tend  to  shorten  life. 

Treatment.  Tlie  patient  should  be  placed  at  rest,  bodily  and 
mentally.  Nutritious  food,  oleum  tnorrhua,  hypophoaphites,  and  w- 
senicum. 

HyoscyamincE  sulphas,  gr.  -^^^(^  (0.002-0.006  Gm.)  three  times 
daily,  is  a  valuable  remedy.  Good  results  have  followed  the  use  of 
hyoscina  hydrobromas,  gr.  ^J  j~tott  (0.00032-0.00065  Gm.)  three  times 
daily.  Mild ^a/2/a«w«,  twice  or  three  times  a  week,  acts  as  a  ner- 
vous stimulant. 

MYXCEDEMA. 

Definition.  A  progressive  disease  characterized  by  an  infiltra- 
tion of  the  connective  tissue  with  a  gelatinous  substance,  general 
failure  of  the  health  and  mental  failure,  due  to  or  associated  with 
atrophy  of  the  thyroid  gland. 

Cretinism  is  considered  very  akin  to  myxoedema,  save  that  it  is  a 
congenital  condition  associated  with  alteration  or  absence  of  the 
thyroid  gland. 

Cachexia  struinipriva,  a  condition  following  the  extirpation  of  the 
thyroid  gland,  especially  in  the  young,  gives  symptoms  resembling 
myxcedema. 

Causes.  The  cause  of  the  atrophy  of  the  thyroid  gland  is  un- 
known. More  frequent  in  women  than  in  men.  Usually  develops 
about  middle  life.  The  disease  is  said  to  have  followed  the  extirpa- 
tion of  the  gland  in  the  adult. 

Morbid.  Anatomy.  Atrophy  of  the  thyroid  gland,  sometimes 
more  advanced  in  one  lobe  than  the  other.  "  The  pituitary  body  has 
been  found  increased  in  size  "  (Wood).  Until  the  functions  of  the 
thyroid  gland  are  more  fully  understood,  the  steps  in  the  changes  re- 
sulting from  its  atrophy  can  not  be  explained. 

Symptoms.  The  disease  develops  slowly,  often  a  number  of 
years  elapsing  before  all  the  characteristic  phenomena  are  present. 
The  face  and  neck,  and  often  other  parts  of  the  body,  have  a  bloated 
appearance.     The  normal  wrinkles  are  obliterated,  the  nose  is  wide 


GENERAL   OR   NUTRITIONAL   DISEASES.  503 

and  thick,  the  Hps  thick  and  everted,  the  mouth  enlarged,  as  is  the 
tongue,  giving  a  coarse  and  broadened  or  mask  like  appearance  to 
the  features.  The  skin  is  denser  and  does  not  pit  on  pressure,  but  is 
pale  or  chalk-like,  or  yellowish-white,  with  often  a  small  reddish 
patch  on  either  cheek.  The  expression  of  the  countenance  is  immo- 
bile and  stupid. 

The  hands  and  feet  are  enlai^ged,  the  skin  is  coarse  and  dry.  The 
shape  of  the  hands  is  changed,  presenting  a  "  spade-like  "  appear- 
ance. 

The  mental  condition  is  sluggish  and  stupid,  with  loss  of  memory 
and  of  interest  in  the  environments  and  affairs  of  life.  Occasionally 
hallucinations  of  sight  occur.  The  tendency  is  toward  a  dementia. 
Patients  often  complain  of  neuralgic  pains  and  numbness  and  a 
sense  of  muscular  weakness.  The  temperature  is  always  below  the 
normal.  Anaemia  develops,  and  often  a  subacute  nephritis  or  a  gly- 
cosuria or  a  terminal  phthisis. 

Diagnosis.  Dropsy  or  a  general  oedema  has  a  superficial  like- 
ness to  myxoedema,  but  a  study  of  the  symptoms  should  prevent 
error,  2iS pitting  on  pressure  does  not  occur  in  myxoedema. 

Prognosis.  Under  treatment  a  great  improvement  can  be  had, 
but  whether  a  permanent  cure  results  is  not  yet  fully  determined. 

Treatment.  Protect  the  surface  by  warm  clothing.  Warm  bath- 
ing, followed  by  inunctions  of  olive  oil,  and  a  nutritious,  easily 
assimilated  diet. 

For  the  disease,  wonderful  results  have  followed  from  the  persistent 
use  oi  thyroid  extract.  The  dose  must  be  carefully  watched.  Begin- 
ning with  gr.  yi  (0.03  Gm.)  after  meals,  gradually  increasing  the  amount 
until  several  grains  a  day  are  administered,  and  continued  for  a  long 
time,  unless  symptoms  of  thyroidism  occur,  when  the  remedy  must  be 
discontinued  for  a  time.  The  evidences  of  thyroidism  are  shown  by 
great  nervousness  and  restlessness,  with  shortness  of  breath,  which 
becomes  embarrassed  upon  exertion  ;  rapid  pulse  with  palpitation ; 
confusion  of  mind,  or  even  delirium,  and  insomnia  and  gastro-intes- 
tinal  disorders. 

For  the  anaemia  and  muscular  weakness  good  results  follow  the  use 
oi  strychmncE  arseniatis,  gr.  eV  (o.ooi  Gm.),  combined  -w'lih.  ferrum. 
Nuclein  might  be  added  to  the  treatment  with  advantage. 


504  PRACTICE   OF    MEDICINE. 


MENTAL  DISEASES. 


MELANCHOLIA. 

Synonyms.     Depression  of  spirits  ;  psychalgia. 

Definition.  A  variety  of  mental  alienation,  characterized  by  more 
or  less  profound  depression  of  the  emotions,  with  either  no  marked 
intellectual  disturbance  or  the  presence  of  more  or  less  incoherence, 
and  the  association  of  hallucinations  and  delusions.  The  cerebral 
mechanism  developing  a  condition  of  supersensitiveness,  all  impres- 
sions being  exaggerated,  and  a  state  of  abnormal  self-consciousness 
existing. 

Varieties.  Melancholia  simplex;  melancholia  hallucinatory; 
melancholia  agitata  ;  melancholia  attonita  ;  melancholia  hypochon- 
driacal ;  chronic  melancholia  ;  senile  melancholia. 

Causes.  Hereditary  predisposition.  Failing  health.  Grief.  Do- 
mestic and  financial  worries.  Neurasthenia.  Menstrual  irregularities, 
pregnancy,  childbirth,  or  lactation.  Climacteric.  Gastric  and  intes- 
tinal irregularities.  Alcoholic  and  sexual  excesses.  Organic  brain 
diseases.  Religion  rarely  causes  insanity,  though  it  frequently  gives 
color  to  it.  Most  frequent  in  women  and  in  the  young.  Attacks  of 
melancholia  are  more  frequent  in  the  spring  and  early  summer 
months,  and  statistics  also  show  that  suicides  are  more  frequent 
during  this  period. 

Pathology.  The  alterations  in  the  nerve  structure,  underlying 
an  attack  of  melancholia,  are  undetermined.  Anaemia  and  sluggish 
nervous  energy  are  constant  phenomena,  but  are  hardly  the  only 
conditions  disturbing  the  cortex. 

Symptoms.  Melancholia  may  be  the  initial  stage  of  a  mania, 
delusional  insanity,  or  paretic  dementia,  or  a  stage  oifoiie  circulaire. 

Mental :  The  cardinal  condition  is  a  feeling  of  depression,  misery,  or 
mental  anguish  or  pain,  for  which  no  adequate  cause  may  exist.  The 
onset  is  usually  gradual,  with  a  disposition  to  neglect  duties  and  self, 
the  patient  worrying  over  a  something  he  cannot  explain.  The 
world  is  dark  and  gloomy,  with  a  foreboding  of  some  awful  calamity 


MENTAL    DISEASES.  505 

that  is  to  affect  or  wreck  the  patient  or  his  family.  Suspicion,  dis- 
trust, and,  often,  fear  of  wife,  children,  relatives,  or  friends.  Insom- 
nia is  a  constant  and  stubborn  symptom.  The  memory  is  maintained, 
and  the  reasoning  faculties  are  usually  intact,  except  upon  the  painful 
sensations.  The  patient  may  sit  quietly,  declining  or  unable  to  talk 
(silent  melancholia,  or  mutism),  or  be  restless,  according  to  the  char- 
acter of  the  emotions  affected. 

Physical :  The  patient  presents  either  an  anxious  or  a  woe-begone 
expression.  Headache,  and  particularly  a  post-cervical  ache,  is  a 
very  constant  symptom.  The  skin  is  dry  and  harsh,  the  respirations 
superficial,  the  cardiac  action  slow  and  feeble  ;  there  is  gastric  catarrh, 
constipation,  and  scanty,  high-colored  urine.  The  tongue  is  flabby 
and  coated,  and  the  appetite  is  poor.  The  refusal  to  take  food  is  most 
characteristic. 

Hallucinatory  melancholia  is  an  aggravated  form  of  the  disease, 
where,  in  addition  to  the  painful  mental  reflexes,  are  distressing  hal- 
lucinations and  illusions,  the  patient  living  in  a  realm  of  terror.  The 
attack  may  be  the  result  of  a  delusion,  but  much  more  frequently  the 
depression  and  foreboding  give  rise  to  the  delusion.  The  delusions 
of  melancholia  are  usually  of  self-accusation,  self-abasement,  and 
justified  persecution;  the  patient  feels  that  he  is  being  punished  for 
some  transgression,  imaginary  or  otherwise. 

The  manias  of  persecution  and  the  monomanias  of  suspicion  are 
all  of  a  melancholic  type,  the  result  of  painful  hallucinations. 

Hypochondriacal  melancholia  shows  all  subjective  impressions  with 
disturbed  memory,  leading  to  the  belief  that  the  bowels  have  been 
removed,  food  cannot  be  digested,  that  the  brain  has  turned  around, 
that  the  blood  cannot  circulate,  and  that  gallons  of  blood  have  been 
drawn  from  the  body.  These  distressed  individuals  are  often  con- 
scious of  every  organ  of  the  body  and  experience  disagreeable  impres- 
sions coming  from  them  all,  and  as  a  consequence  are  irritable,  fretful, 
and  exacting.  It  is  to  be  remembered  that  not  uncommonly  these 
patients  really  have  an  organic  disease  giving  a  foundation  for  the 
delusions. 

Melancholia  agitata  are  those  sad  cases  in  continual  agitation,  in 
which  the  fearful  and  distressful  thoughts  and  imaginations  cause 
wringing  of  the  hands,  restless  walking,  rhythmic  swaying  of  the  body, 
and  prayers  beseeching  help,  with  tears  flowing  down  their  cheeks, 
crying  out  for  assistance  and  protection.     Incoherence  and  violent 


506  PRACTICE    OF    MEDICINE. 

impulses  are  frequent,  the  excitement  often  resembling  an  attack  of 
mania. 

Melancholia  attonita,  or  melancholia  with  stupor,  the  patients 
seeming  to  be  overwhelmed,  sitting  mute,  motionless,  and  expres- 
sionless, refusing  to  assist  themselves  in  any  way,  and  often  requiring 
mechanical  feeding.  Memory  is  usually  impaired  in  this  variety  ; 
and  attacks  of  violence  may  occur. 

Chronic  melancholia  is  the  continuation  of  the  depression  over  a 
long  period,  the  individual  living  in  the  fear  of  impending  danger  or 
punishment  for  supposed  acts  for  long  periods  of  time,  often  with 
apparent  lucid  periods. 

Senile  melancholia  is  a  condition  of  extreme  mental  distress  associ- 
ated with  beginning  senile  dementia. 

Suicidal  impulses  are  present  in  a  fair  proportion  of  cases  of  mel- 
ancholia, and  unless  there  be  everlasting  vigilance  the  patient  will 
succeed  in  his  insane  desire. 

Diagnosis.  The  cases  of  simple  melancholia  are  readily  deter- 
mined. Melancholia  agitata  is  frequently  mistaken  for  acute  mania. 
Melancholia  attonita  closely  resembles  acute  dementia — a  condition, 
it  is  but  fair  to  mention,  denied  by  many  alienists. 

Prognosis.  A  typical  attack  of  melancholia  runs  a  definite 
course,  not  unlike  the  typical  course  of  a  fever.  Favorable  in  the 
mild  cases  of  all  forms  not  associated  with  organic  disease,  and  who 
have  not  reached  the  climacteric.  Delusional  melancholia  has  the 
most  unfavorable  prognosis.  Pronounced  cases  of  melancholia 
attonita  are  more  apt  to  terminate  in  dementia  than  any  other  variety. 

Treatment.  Change  of  environment  and  rest  are  essential. 
Attention  to  the  gastro-intestinal  canal  is  of  the  greatest  importance, 
as  the  dyspepsia  and  constipation  of  melancholic  patients  is  a 
barrier  to  their  recovery.  Frequent  bathing,  with  friction  to  the  sur- 
face, aids  in  the  eliminative  action  of  the  skin.  The  diet  must  be 
of  the  most  nutritious  character.  If  food  be  persistently  refused, 
mechanical  feeding  must  be  practiced.  The  late  Dr.  Gray  was  a 
strong  advocate  of  small  doses  of  opium,  or  morphina,  in  acute 
melancholia,  and  in  properly  selected  cases  it  is  a  most  valuable 
agent.  Tinctures  quebracho,  3j-ij  (4-8  Gm.),  well  diluted,  three  times 
daily,  is  often  a  valuable  remedy.  If  the  arterial  tension  is  relaxed, 
good  results  follow  the  use  of  digitalis.   Sodii  phosphas  is  often  useful. 

Many  cases  of  melancholia  seem  to  be  due  to  a  brain  fatigue,  and 


MENTAL   DISEASES.  50T 

if  the  patient  can  be  given  many  hours'  sleep  in  the  early  days  of 
the  attack  recovery  is  assured. 

I  have  seen  excellent  results  in  melancholia  attonita  from  cannabis 
indiccB  in  increasing  doses. 

Such  tonics  as  quinince  sulphas,  arsenic mn,ferrum,  and  sirychttirics 
sulphas  or  arseniatis  are  all  of  value  in  building  up  the  patient.  As 
the  strength  improves,  open-air  exercise  must  be  added  to  the  other 
means  used. 

Insomnia  must  be  combated  by  evening  bathing  and  feeding,  and 
the  use  of  chloral,  trional,  sulphonal,  or  hyoscina  at  bed-time. 


MANIA. 

Synonyms.     Insanity ;  madness. 

Definition.  An  intense  mental  exaltation,  with  great  excitement, 
loss  of  self-control,  with,  at  times,  absolute  incoherence  of  speech, 
and  loss  of  consciousness  and  memory.     (Clouston.) 

Mania  is  a  condition  characterized  by  an  abnormal  exaltation  and 
activity  of  the  mental  functions, — the  intellectual  faculties,  the  emo- 
tions, and  the  will, — and  may  show  itself  by  irrational  talking  and 
acting,  by  delusions,  illusions,  and  hallucinations,  and  by  unusual 
muscular  activity  or  movements.     (Chapin.) 

A  mental  condition  in  which  there  is  an  emotional  exaltation,  ac- 
companied by  illusions,  hallucinations,  delusions,  great  mental  and 
physical  excitement,  and  a  complete  loss  of  the  inhibitory  power  of 
the  will ;  in  acute  cases,  and  frequently  in  chronic  forms  of  the  dis- 
ease, there  is  a  marked  destructiveness  and  a  tendency  to  violence. 
(Wood.) 

An  attack  of  mania  may  be  acute,  subacute,  or  chronic. 

Causes.  Inflammation  or  other  organic  disease  of  the  brain  or 
its  membranes.  Mental  shock  or  strain.  Worry — domestic,  moral, 
or  financial.  Excesses  in  alcohol,  venery,  or  tobacco.  Ovarian  dis- 
ease, or  menstrual  irregularities.  Climacteric  in  those  of  nervous 
disposition.  Pregnancy,  parturition,  or  lactation.  Nephritis.  Anae- 
mia.    Syphilis.     Hereditary  predisposition. 

Pathology.  There  are  no  constant  morbid  changes  associated 
with  mania.  In  all  varieties  of  acute  insanity  there  exists  vitiated 
nervous  energy  or  impaired  vitality,  the  result  of  overexcitement  or 


508  PRACTICE    OK    MKDICINE. 

overstimulation,  motor  disturbance,  or  auto-infection,  the  result  of 
the  imperfect  elimination  of  the  products  of  tissue  waste.  "  There  is 
no  reason  why  a  mere  dynamical  brain  disturbance  should  not  kill 
and  leave  no  structural  trace,  any  more  than  that  it  should  for  months 
abolish  judgment,  affection,  and  memory,  and  then  passoffand  leave 
the  brain  and  all  its  functions  intact."     (Clouston.) 

If  death  follow  the  acute  symptoms,  the  vessels  of  the  brain  and 
membranes  are  engorged,  but  in  the  majority  of  instances  the  brain 
structure  is  normal. 

If  death  occur  in  chronic  mania,  the  most  frequent  change  found 
will  be  a  thickened  and  adherent  dura  mater.  As  observed,  any  form 
of  organic  change  may  be  {ound post-mortem  in  those  dying  of  any 
form  of  mania. 

Symptoms.  Acute  Mania:  The  onset  may  be  abrupt,  or  fol- 
lowing a  period  of  emotional  depression,  associated  with  lassitude, 
feeling  of  unrest,  disinclination  to  work,  and  disorders  of  the  gastro- 
intestinal canal,  with  insomnia  and  an  introspection  ;  these  symptoms 
are  termed  the  melancholic  stage  of  mania. 

T\\Q  maniacal  stage  \s  characterized  by  loud  talking,  intense  ego- 
tism, violent  motions  of  the  limbs  and  body,  great  restlessness,  and 
excitement ;  the  thoughts  flow  with  wonderful  freedom  and  amazing 
rapidity,  the  condition  often  resembling  the  symptoms  of  early  alco- 
holic intoxication  ;  as  the  exaltation  continues  the  patient  becomes 
either  sullen,  irritable,  and  angry,  offering  violence  to  those  around 
him,  or  he  becomes  garrulous,  talking  of  his  personal  affairs,  is 
confidential  and  communicative  to  strangers,  often  making  egotistic 
offers,  passing  frequently  into  incoherence  of  language  and  action. 
Sexual  passions  are  frequently  exalted,  and  acts  of  masturbation 
practiced,  with  outbreaks  of  vulgar,  obscene,  and  profane  language, 
which  is  entirely  foreign  to  the  individual  in  mental  health.  Delu- 
sions are  an  almost  constant  symptom,  of  a  superficial  or  transitory 
character,  changing  with  every  new  appearing  mood.  The  maniacal 
patient  is  sleepless,  or  may  have  short  naps,  at  once  continuing  his 
chatter  on  awakening. 

Any  attack  may  show  all  of  the  symptoms  mentioned,  or  any  one 
or  more  of  them,  but  the  great  majority  of  cases  show  intense egotisin, 
loud  talking,  violent  motion  of  limbs  or  body,  hurry,  excitemetit,  in- 
somnia, incoherence,  and  incessant  noise. 

The  course  of  an  attack  shows  periods  of  remissions  and  exacerba- 


MENTAL   DISEASES.  509 

tions,  with  nocturnal  crises  ;  loss  of  flesh  and  mental  weakness  are 
often  marked  as  the  attack  progresses. 

Acute  delirious  mania,  typhomania,  is  a  psychosis  of  sudden  onset, 
attended  with  increased  bodily  temperature,  dry  tongue,  quick,  feeble 
pulse,  scanty  urine,  and  marked  by  delirium  with  sensuous  hallucina- 
tions, marked  incoherence,  restlessness,  refusal  of  food,  loss  of 
memory,  and  rapid  bodily  wasting,  terminating  frequently  in  death. 

Amenorrhaeal  mania  are  attacks  of  mania  occurring  at  the  men- 
strual epoch.  Homicidal,  suicidal,  and  various  hysterical  impulses 
are  frequent. 

Mania-a-potu  is  an  attack  of  acute  delirium,  due  to  alcoholic  ex- 
cesses in  those  engaged  in  a  sudden  debauch,  or  who  have  drunk 
heavily  and  eaten  little,  for  a  comparatively  short  period. 

Asthenic  mania,  in  which  there  is  general  ansmia  associated  with 
neurasthenic  symptoms. 

Dancing  mania  is  a  hysterical  mental  state  in  which,  through  sym- 
pathy and  imitation,  dancing  of  a  most  grotesque  and  extravagant 
character  occurs.     Usually  epidemic. 

Delusional  mania  is  the  result  of  fixed  delusions,  either  causing  or 
associated  with  the  maniacal  outbreak. 

Erotic  mania,  erotomania,  presents  systematized  delusions  of  an 
erotic  character,  not  necessarily  accompanied  by  animal  sexual  desire. 
Nymphomania  is  a  morbid,  irresistible  impulse  to  satisfy  the  sexual 
appetite,  and  is  peculiar  to  the  female  sex. 

Epileptic  mania  follows  an  epileptic  paroxysm,  and  is  often  of  a 
most  violent  kind,  the  maniacal  acts  being  of  the  most  treacherous 
and  malicious  character. 

Hallucinatory  mania  presents  visual,  auditory,  olfactory,  and  other 
sense  hallucinations. 

Homicidal  mania  is  any  variety  of  mental  disease  in  which  there  is 
a  desire  or  an  attempt  on  the  part  of  the  patient  to  commit  murder. 
The  condition  may  be  the  result  of  delusions  that  the  persons  attacked 
either  are  persecuting  or  going  to  kill  the  patient,  or  of  the  excessive 
excitement  that  vents  itself  in  destructiveness,  combativeness,  or 
desire  to  kill,  or  there  may  be  a  morbid  desire,  impulse,  or  craving  to 
do  murder,  or  the  homicidal  act  may  be  unconsciously  done  during 
an  acute  delirium,  or  a  paretic  or  epileptic  maniacal  impulse.  In 
cases  of  murder  the  question  of  responsibility  or  the  difference  between 
the  insane  criminal  and  the  criminal  is  not  always  readily  determined. 


510  PRACTICE  OK  mf:dicinr. 

Willi  insane  criminals,  in  the  act  Hsclf  lies  the  satisfaction  and 
not  the  object,  while  with  criminals  the  act  is  only  a  means  to  an  end  ; 
to  the  former  crime  is  a  pleasure,  to  the  latter  a  paying  business, 
necessitating,  it  may  be,  disagreeable  or  horrible  acts. 

Morphinomania  is  the  insane  craving  for  the  stimulating  action  of 
morphia — a  moral  insanity. 

Puerperal  7nania  is  the  maniacal  outbreak  as  seen  in  the  puerperal 
woman.  This  is  now  thought  to  be  of  septic  origin,  although  the 
mental  strain  through  which  the  female  has  been  passing  is  a  predis- 
posing factor  in  those  who  have  a  neurotic  history. 

Transitory  mania,  or  ephemeral  mania,  is  a  rare  form  of  maniacal 
excitement  of  sudden  onset,  violent  and  decided  in  character,  accom- 
panied by  great  insomnia,  incoherence,  and  more  or  less  complete 
unconsciousness  of  familiar  surroundings.  The  attack  as  suddenly 
terminates,  the  duration  being  from  a  few  hours  to  a  few  days. 

Senile  mania  is  the  mental  exaltation  occurring  in  persons  with 
senile  arterial  changes  or  senile  cerebral  atrophy.  Soon  followed  by 
dementia. 

Recurrent  mania,  or  chronic  mania  with  lucid  intervals  of  longer  or 
shorter  duration.     Generally  of  alcoholic  origin. 

A  maniacal  outbreak  may  present  any  one  or  a  number  of  the 
varieties  named. 

Chronic  Mania  :  A  condition  of  r^«/z«z^a/ mental  exaltation,  the 
acute  symptoms  having  continued  in  a  chronic  course.  The  line  that 
distinguishes  between  an  acute  and  chronic  mania  must  always  be 
somewhat  arbitrary  and  unscientific.  The  duration  of  the  mania 
beyond  twelve  months  is  usually  considered  sufficient  to  determine 
the  condition,  and  this  is  well,  as  it  precludes  the  possibility  of  term- 
ing the  condition  incurable.  If  the  term  chronic  mania  was  restricted 
to  those  cases  in  which,  between  the  exacerbations  of  restlessness, 
excitement,  and  destructiveness,  were  evidences  of  dementia,  less 
confusion  would  occur. 

Terminations  of  Mania.  About  fifty  per  centum  of  acute 
manias,  not  due  to  organic  disease,  recover  after  periods  varying  from 
one  month  to  several  years.  A  fair  proportion  of  cases  make  a  partial 
recovery  and  are  able  to  return  to  their  work,  but  always  showing 
some  alteration  in  character  or  affection,  or  some  eccentricity,  or  a 
slight  mental  weakness.  About  twenty  per  centum  of  cases  terminate 
in  dementia  or  mental  death,  and  this  is  always  the  fear  in  each  case. 


MENTAL   DISEASES.  511 

Two  per  centum  of  cases  die,  either  the  result  of  exhaustion  or  from 
the  organic  condition  causing  or  associated  with  the  attack. 

Prognosis.  The  question  of  recovery,  partial  or  complete,  is 
always  difficult  to  determine,  depending  upon  the  cause,  temperament, 
disposition,  education,  nationality,  and  the  normal  mentality  of  the 
individual.  Recovery  is  usually  gradual ;  rarely  sudden  restoration 
occurs. 

Favorable  indications  are :  sudden  onset,  short  duration,  youth  of 
patient,  absence  of  fixed  delusions,  good  appetite,  increasing  hours 
of  sleep  ;  moderate  or  no  increase  in  temperature,  pulse,  and  respira- 
tion ;  no  evidences  of  mental  weakness,  no  paralysis  or  alteration  of 
pupils  or  articulation,  no  epilepsy,  no  unconsciousness  to  the  calls  of 
nature,  and  no  former  attacks.  Unfavorable  indications  are  the 
opposite  of  these,  and  also  the  presence  of  organic  brain  disease,  or 
a  strong  hereditary  tendency,  or  the  possession  of  an  excitable  dispo- 
sition or  nervous  diathesis. 

Treatment.  The  indications  for  treatment  are  to  quiet  the  exalted 
mentality  and  to  promote  constructive  metamorphosis.  Every  means 
should  be  used  to  lessen  the  excitement  of  the  patient  and  produce 
refreshing  sleep.  A  hot  or  warm  bath  is  frequently  one  of  the  most 
soothing  means  of  reducing  excitement;  changing  the  environment 
of  the  patient  and  placing  him  under  the  care  of  a  good,  firm,  but 
kind  and  intelligent  nurse  is  of  importance ;  the  society  or  visits  of 
the  family  or  friends  must  be  forbidden,  for  visits  act  as  stimulants  to 
the  disordered  intellect  and  encourage  discussion  on  the  part  of  the 
patient  as  to  the  character  of  the  treatment,  and  thus  reduce  the  dis- 
cipline so  essential  to  early  recovery. 

If  means  of  this  character  are  unavailing,  and,  unfortunately,  in  the 
majority  of  attacks  they  will  be,  then  resort  must  be  had  to  sedatives, 
for  every  day's  continuance  of  the  maniacal  outbreaks  lessens  the 
chances  of  restoration.  Amongst  the  drugs  having  a  distinct  value 
are  hyoscince  hydrobromas,  gr.  ^oo  eV  (0.00032-0.001  Gm.),  repeated 
two  or  three  times  daily,  watching  its  effect  on  the  pupils  ;  sulphonal, 
gr.  XX  (1.3  Gm.),  repeated  with  caution,  watching  its  effect  upon  the 
heart  and  respiration  ;  chloralamidtan,  gr.  xxx-xl  (2-2.6  Gm.),  repeated 
three  or  four  times  daily  ;  or,  trional,  gr.  xxx  (2  Gm.),  repeated  in  two 
or  four  hours  ;  this  latter  is  one  of  the  most  reliable  drugs  for  maniacal 
excitement  and  insomnia  we  now  possess.  I  have  seen  excellent 
results  from  the  use  of  passiflora  mcarnata,  either  as  a  tinctura,  in 


512  rUACTICE    OF    MEDICINK. 

foj-'^Sij  (4-8  Cc.)  doses,  several  times  daily,  or  as  exlractum  fluidum 
in  smaller  doses.  Patients  with  much  excitement  and  a  weak  pulse 
are  benefited  with  full  doses  of  the  bromides  and  digilalis.  If  the 
muscular  excitement  is  pronounced,  good  results  follow  morphina 
sulphas,  hypodermically ;  it  may  be  combined  with  either  atropina 
sulphas,  hyoscincB  hydrobromas,  or  duboisina  sulphas. 

In  attacks  of  acute  mania,  with  flushed  face,  throbbing  arteries, 
full  pulse,  and  delirious  excitement,  excellent  results  follow  the 
use  oi extracUwi gelsemii Jluidwn ,  n\,ij  (o.  1 2  Cc),  every  hour,  until  dila- 
tation of  the  pupils  and  ptosis  develop,  unless  improvement  sooner 
occur;  tinciurce  verahi  viridis,X(\j]-y  (0.12-0.3  Co.),  is  also  useful. 
Post-epileptic  excitement  is  best  controlled  with  large  doses  of  chloral, 
by  the  mouth  or  rectum.  Ice  or  cold  to  the  head  is  useful  in  cases 
with  flushed  face  and  throbbing  temporals. 

The  general  condition  of  the  patient  calls  for  the  most  prompt  and 
efficient  treatment.  Attention  to  the  gastro-intestinal  canal  and  kid- 
neys is  of  paramount  importance,  as  many  attacks  of  mania  are  the 
result  of  auio-in/oxicafion  from  the  retention  of  the  products  of  mal- 
assimilation  and  tissue  waste.  The  diet  should  be  of  the  most  nutri- 
tious character,  administered  at  frequent  intervals — peptonized  or  hot 
milk,  hot  broths,  eggs,  and  often  alcoholic  or  malt  liquors. 

Patients  not  infrequently  refuse  food  on  account  of  lack  of  appe- 
tite, abhorrence  for  food,  or  from  fear  of  poisoning,  when  recourse 
must  be  had  to  the  naso-stomachic  tube,  or  nutritive  enemata.  If  the 
breath  be  heavy,  the  tongue  badly  coated,  the  bowels  costive,  and 
the  skin  sallow,  the  very  best  results  follow  washing  out  the  stomach, 
provided  the  maniacal  condition  permits. 

Tonics  are  of  great  value,  a  combination  like  the  following  always 
being  beneficial : 

R.     Quininse  sulphat. , gr.  xlviij  3.1       Gm. 

Strychninix;  sulphat., gr.  ss  .032  Gm. 

Acid,  hydrochlor.  dil., f  .^ ''j  12.  Cc. 

Aqure  chloroformi, f  3  ''j  9'^-         Co. 

Aquce  menthce  pip.,    .    .  q.  s.   ad  f3vj  ad   180.  Cc.  M. 

SiG. — Dessertspoonful,  diluted,  every  four  or  six  hours. 

The  question  of  removal  to  a  hospital  for  the  insane  arises  in  nearly 
all  cases,  and  should  in  my  judgment  be  answered,  in  the  vast  ma- 
jority of  instances,  in  the  affirmative,  as  the  discipline,  regular  hours, 
and  order  of  a  well-managed  hospital  for  the  insane  have  a  most 
remarkable  effect  on  the  majority  of  insane  patients, 


MENTAL   DISEASES.  513 


EPILEPTIC  INSANITY. 


Definition.  A  mental  condition  caused  by  or  the  result  of  epi- 
lepsy. 

Causes.  The  careful  study  of  the  brain  of  those  dying  having 
epileptic  insanity  has  failed  to  determine  why  some  epileptics  suffer 
from  any  of  the  insanities  and  others  have  their  normal  mentality, 
and  another  group  are  better  after  a  convulsion. 

I  am  familiar  with  ten  cases  of  epilepsy  who  all  seem  much  brighter, 
mentally,  after  their  paroxysm,  but  in  whom,  after  a  drinking  bout, 
each  epileptic  attack  is  followed  by  a  wicked  homicidal  mania  of 
many  weeks'  duration. 

Varieties.  Pre-epileptic  mania  ;  post-epileptic  mania  ;  dementia 
epileptica;  imbecility  with  epilepsy. 

Symptoms.  The  mental  changes  constituting  epileptic  insanity, 
save  in  the  cases  of  epilepsy  with  imbecility  or  idiocy,  develop  after 
some  years  of  the  ordinary  epileptic  paroxysms. 

P/'g-eptVep^tc  mania  has  atta-cks  of  Tndinia.  some  days  or  hours  pre- 
ceding the  epileptic  convulsion.  The  patient  is  morose,  irritable,  and 
threatening,  often  making  homicidal  attacks  on  those  around  him,  be 
they  friends  or  foes.  Rarely  the  epileptic  seizure  is  replaced  by  various 
insane  or  so-called  hysterical  acts,  as  fits  of  dancing,  laughing,  crying, 
screaming,  swearing,  or  scolding. 

Post-epileptic  vian-ia  follows  the  epileptic  paroxysm,  either  taking 
the  place  of  the  comatose  state  or  following  it.  The  maniacal  acts 
during  these  outbreaks  are  often  of  the  most  desperate  and  im- 
pulsive character,  many  an  asylum  physician  and  attendant  carrying 
scars  the  result  of  attacks  of  post-epileptic  maniacs. 

Epileptic  dementia  is  the  terminal  mental  obliquity  resulting  in 
about  thirty  per  centum  of  insane  epileptics  who  do  not  succumb 
before  to  nephritis  or  tuberculosis. 

Epileptic  imbecility  is  a  congenital  condition  in  which  epilepsy  and 
imbecility  are  associated. 

Prognosis.  The  great  majority  of  persons  suffering  from  epileptic 
insanity  develop,  sooner  or  later,  either  nephritis  or  tuberculosis. 

Recovery  from  epileptic  mania  is  a  rare  occurrence,  although  I 
am  familiar  with  two  cases.     Thirty  per  centum  of  epileptic  maniacs 
progress  to  dementia  in  from  five  to  ten  years, 
33 


514  PRACTICE    OF    MF.DiriNE. 

Treatment.  There  is  no  doubt  but  that  full  doses  of  the  bro)nidei 
lessen  the  severity  and  frequency  of  the  paroxysms.  If  the  attack 
can  be  anticipated,  it  may  sometimes  be  averted  by  an  enema  of 
chloral,  gr.  xx-xxx  (1.3-2  Gm.),  or  chloralamidum,  gr.  xl-lx  (26-4 
Gm.),  or  amyl nitris,  Tt\^v  (0.3  Cc),  by  inhalation  or  by  stomach.  For 
the  condition  of  status  epilepticus  the  following  combination,  alternated 
with  saline  purgatives,  has  given  good  results : 

R.     Chloral, gr-  xx  1.3  Gm. 

Tinct.  cannab.  incHcae, Tr^xv  I.     Cc. 

Inf.  digitalis, f5J  30.     Cc.  M. 

SiG. — Administer  as  enem.ita  every  three  or  four  hours. 

The  use  of  opium  for  a  long  period  has  broken  up  the  recurrent 
maniacal  attacks  in  several  patients  under  my  care. 

The  general  condition  of  the  patient  must  receive  careful  attention, 
as  there  is  a  strong  tendency  to  the  development  of  nephritis,  tuber- 
culosis, and  gastric  catarrh.  This  class  of  patients  are  great  feeders — 
often  gluttons — and  are  sure  to  eat  more  than  they  can  properly  as- 
similate.    Free  action  of  the  bowels  and  kidneys  must  be  promoted. 

Never  contradict,  nor  attempt  to  reason  with,  an  epileptic  during 
the  period  of  excitement. 

CIRCULAR  INSANITY. 

Synonym.     Folie  circulaire. 

Definition.  A  mental  disease  characterized  by  regularly  alternat- 
ing and  recurring  periods  of  mental  exaltation,  depression,  and  semi- 
lucidity. 

Causes.  Hereditary  predisposition.  The  exciting  causes  are 
any  of  those  conditions  which  depress  the  brain  or  general  system. 

Pathology.  There  is  no  characteristic  lesion  associated  with  cir- 
cular insanity. 

Symptoms.  Essentially  a  chronic  condition  and  probably  incur- 
able. The  disease  usually  begins  as  a  melancholia,  the  depression 
being  an  apathy  and  torpor  rather  than  a  mental  pain,  and  suicidal 
feelings  and  impulses  are  rare.  This  condition  is  soon  succeeded  by 
mania,  a  mental  exaltation  with  hyperassthesia  and  exaggeration  of 
nervous  functions,  the  reasoning  power  well  retained  ;  this  is  in  turn 
followed  by  a  semi-lucid  interval,  often  giving  promise  of  recovery, 
to  be  sooner  or  later  followed  by  another  cycle.    These  periods  fol- 


MENTAL   DISEASES.  515 

low  each  other  with  remarkable  regularity,  each  being  of  the  same 
duration.     Rarely  the  various  periods  are  of  irregular  duration. 

The  general  health  is  well  maintained,  the  patient  gaining  in  flesh 
during  the  stages  of  depression  and  lucidity  and  losing  during  the 
period  of  exaltation. 

Diagnosis.  The  regularity  of  the  different  periods  soon  estab- 
lishes the  diagnosis. 

Prognosis.  Incurable.  Ending  in  dementia  after  a  lapse  of 
several  years. 

Treatment.  Attention  to  the  general  health  and  meeting  the 
symptoms  of  the  different  periods  as  they  recur.  No  means  known 
to  prevent  the  recurrence  of  the  periods. 


KATATONIA. 

Synonyms.     Alternating  insanity  ;  Kahlbaum's  insanity. 

Definition.  A  mental  disease  characterized  by  irregular  cyclical 
symptoms,  ranging  from  melancholia  to  mania,  followed  by  stupidity 
and  confusion,  with  cataleptoid  phenomena,  followed  by  lucidity  for 
a  time,  recovery,  or  passing  to  a  dementia. 

Causes.  Hereditary  predisposition.  The  exciting  causes  are  usu- 
ally the  result  of  some  excess.  Rarely  associated  with  organic  brain 
disease. 

Pathology.  No  characteristic  lesions  have  been  found  associated 
with  katatonia. 

Symptoms.  A  typical  case  begins  as  a  melancholia,  the  mental 
depression,  uneasiness,  and  distress  followed  after  a  variable  period 
by  mania,  associated  with  hallucinations  and  delusions.  This  period  is 
followed  in  turn  by  a  condition  oi  attonita,  or  rigidity  and  immobility, 
or  a  cataleptoid  paroxysm.  Any  of  the  stages  may  be  followed  by 
confusional  syvcv^\.oms,  or  a  true  dementia  may  develop.  During  the 
maniacal  stage  there  is  a  tendency,  in  many  cases,  to  histrionic  and 
sermon-like  declamation,  or  the  speech  may  be  of  the  verbigeration 
character — that  noisy,  incoherent,  and  meaningless  speech  seen  in 
many  manias,  composed  largely  of  the  constant  repetition  of  a  few 
words  or  phrases  without  sense  or  sequence  (onomatomania). 

During  the  stage  of  attonita  the  presence  of  the  so-called  mutism 
QV  mutacismus ,  "  a  pathological  tendency  to  be  silent,"  may  continue 


51  ()  PRACTICE    OF    MEDICINE. 

for  days,  weeks,  or  months,  or  it  may  be  interrupted  by  periods  of 
verbigeration. 

The  immobility  or  rigidity  so  characteristic  of  a  period  of  katatonia 
is  frequently  alternated  with  automatic,  incessant,  and  monotonous 
movements — the  stereotyped  movements. 

Patients  suffering  from  katatonia  often  refuse  food  for  days  at  a 
time  and  then  suddenly  present  symptoms  of  boulimia.  Vasomotor 
and  trophic  changes  are  frequent,  one  of  the  most  constant  being 
cyanosis  of  the  hands  and  other  peripheral  parts.  Haematoma  auris, 
insane  ear,  or  perichondritis  auricuhx;,  is  frequent.  Epileptiform 
attacks  may  usher  in  the  disease  or  occur  during  any  of  its  stages. 

Diagnosis.  It  may  be  diagnosed  as  melancholia,  mania,  or  a 
dementia,  depending  upon  which  of  the  cycles  be  first  observed, 
but  after  being  under  observation  long  enough  to  note  a  complete 
cvcle  the  diagnosis  is  readily  determined.  Katatonia  differs  from 
circular  insanity  in  the  presence  of  the  stage  of  attonita  and  catalepsy. 

Prognosis.  The  disease  may  continue  for  a  number  of  years 
and  recovery  follow,  but  as  a  rule  the  prognosis  is  unfavorable. 

Treatment.  Attention  to  the  general  condition,  and  combating 
the  various  symptoms  as  they  arise.  In  cases  associated  with  anaemia, 
arsenicjon  and  strychnina  seem  to  be  valuable.  Two  cases  were 
rapidly  improved  with  small  doses  of  hyoscifice  hydrobromas,  gr. 
^^y_^^jj  (0.00022-0.00032  Gm.)  morning  and  evening.  When  food  is 
refused  by  the  insane,  and  stomachic  or  nasal  tube  or  rectal  feeding 
is  necessary,  the  stage  of  food  refusal  is  often  wonderfully  shortened 
by  adding  sulphonal,  gr.  x-xv  (0.6-1  Gm.),  to  each  feeding. 


DELUSIONAL  INSANITY. 

Synonyms.  Delusional  mania  ;  delusional  melancholia  ;  primary 
delusional  insanity. 

Definition.  A  mental  state,  with  fixed  or  partly  systematized 
delusions,  associated  with  either  brain  exaltation  or  excitement  ^vitli- 
f«/ maniacal  acts,  or  a  mental  depression,  minus  the  somatic  symp- 
toms of  melancholia. 

An  insane  delusion  is  a  false  belief  for  which  there  is  or  may  be  no 
reasonable  foundation  and  which  would  be  incredible  under  the  given 
circumstances  to  the  same  person  if  of  sound  mind,  and  concerning 


MENTAL   DISEASES.  517 

which  his  mind  is  not  open  to  permanent  correction  through  evidence 
or  argument. 

"An  insane  delusion  is  a  belief  in  something  that  would  be  in- 
credible to  sane  people  of  the  same  class,  education,  or  race  as  the 
person  who  expresses  it,  this  resulting  from  diseased  working  of  the 
brain  convolutions." 

Causes.  Cerebral  and  bodily  exhaustion  the  result  of  overwork, 
neglect  of  personal  hygiene,  or  alcoholic,  tobacco,  drug,  or  sexual 
excesses — a  neurasthenia.  Impairment  of  the  nervous  centers,  the 
result  of  fevers  or  shock.  Climacteric  period,  worry,  and  insufficient 
food. 

Pathology.  Delusional  insanity  is  a  subacute  or  chronic  condi- 
tion ;  death  seldom  occurring,  and  when  it  does  is  the  result  of  an 
intercurrent  physical  malady.  In  the  few  such  cases  in  which  post- 
mortem examinations  have  been  made,  the  vessels  of  the  brain  were 
found  torpid  or  dilated — a  vasomotor  paresis  causing  an  imperfect 
cerebral  circulation. 

Symptoms.  Either  following  an  attack  of  acute  mania  or  melan- 
cholia, but  itiore  commonly  without  either  of  these  conditions,  occurs 
a  set  delusion  or  delusions,  which,  to  the  patient,  are  so  real  that  no 
amount  of  argument  can  dispel  his  or  her  belief.  These  cases  are  often 
classed  as  manias  or  melancholias,  but,  as  they  do  not  run  the  ordi- 
nary course  of  either  of  these  conditions,  they  are  best  classed  clinic- 
ally by  themselves.  The  acuteness  or  subacuteness  of  the  attack  distin- 
guishes them,  from  paranoia.  Among  the  almost  endless  variety  of 
delusions  mention  will  be  made  of  a  few  that  have  come  under  recent 
notice  :  A  young  man  of  twenty  believes  that  he  is  President  Cleve- 
land ;  another  patient,  a  driver,  believed  for  ten  months  that  he  was 
the  owner  of  a  thousand  horses,  any  one  of  which  was  worth  thousands 
of  dollars ;  he  made  a  perfect  recovery  and  now  laughs  at  his  old 
delusions.  A  young  man  of  twenty-five  believes  his  mother  is  not 
his  mother,  but  the  woman  he  boarded  with,  and  that  his  brothers  and 
sisters  are  her  children  but  no  relation  to  him.  A  young  woman  of 
thirty  believes  she  is  pregnant  by  a  prominent  merchant ;  the  fact 
being  she  is  not  and  never  has  been  pregnant.  The  majority  of  the 
delusions  are  of  an  egotistical  character,  but  lack  the  conduct  or 
appearance  of  the  position  due  to  the  character  of  the  delusion.  A 
patient  with  ragged  clothing  will  assure  you  that  he  is  worth  millions, 
and  yet  sees   nothing  inconsistent   between   his   delusion    and  his 


518  PRACTICE    OF    MEDICINE. 

personal  appearance.  Another  will  assure  you  of  his  vast  business 
interests,  and  yet  remains  contented  in  the  hospital  wards,  laboring 
faithfully  in  the  kitchen  or  laundry.  A  woman  assures  you  that  she 
is  the  great  Patti,  receiving  thousands  of  dollars  for  each  operatic 
performance,  and  yet  is  apparently  happy  in  the  sewing-room. 

An  hallucination  is  an  imperfect  perception  through  any  one  of  the 
senses.  A  person  who  imagines  that  he  sees  something,  or  hears 
something,  or  tastes  something,  or  feels  or  smells  something  that  he  is 
not  seeing,  hearing,  tasting,  feeling,  or  smelling,  has  an  hallucination. 

Delusional  insanity  is  often  based  upon  the  development  of  hallu- 
cinations of  the  special  senses,  that  of  hearing  being  the  most  fre- 
quent ;  patients  hear  "  voices  "  telling  them  what  to  do  or  not  to  do, 
and  a  delusion  is  built  up  and  developed.  Again,  "  voices"  upbraid 
them  or  charge  them  with  various  acts,  and  upon  this  is  developed  a 
persecutory  delusion  that  causes  them  much  unrest.  The  following 
case  has  lasted  for  five  years,  and  while  the  patient  is  at  times 
apprehensive  of  some  evil  that  may  result  to  her,  and  uses  judg- 
ment to  protect  herself,  yet  is  not,  nor  never  has  been,  melan- 
cholic, or  shown  any  evidences,  other  than  her  present  belief,  of 
mental  failure.  She  enjoys  fair  health,  and  partakes  of  the  world's 
pleasures.  Six  years  ago  her  husband  suddenly  died  and  the  settling 
of  a  large  estate  was  thrown  upon  the  patient.  Sitting  in  her  hotel 
at  the  window,  about  five  years  ago,  she  saw  a  man  come  to  the 
window  in  a  building  opposite  to  where  she  was,  and  make  some 
motion  to  her.  She  was  greatly  alarmed.  That  evening,  while  walk- 
ing on  one  of  the  busiest  streets  of  the  city,  she  distinctly  heard  a 
young  man,  in  passing,  make  an  improper  proposal  to  her,  and  she 
has  never  walked  on  that  street  since  without  the  same  thing  occur- 
ring, although  not  always  by  the  same  person.  Her  daughter,  who 
accompanied  her,  did  not  hear  the  proposal,  nor  has  she  ever  heard  it, 
although,  I  regret  to  say,  is  gradually  becoming  convinced  it  must  be 
true.  Now  for  the  sequel :  the  woman  is  not  depressed  or  worried, 
shows  no  evidences  of  melancholia,  talks  about  the  affair  as  if  it  were 
a  fact,  which  it  unfortunately  appears  to  her,  and  avoids  the  unpleas- 
antness by  never  again  walking  on  the  particular  street  nor  going  in 
that  neighborhood. 

Again,  visions  appear,  which  result  in  delusions  of  personal  impor- 
tance. Taste  and  smell  may  be  perverted,  causing  prolonged  fasting, 
often  from  fear  of  poisoning. 


MENTAL   DISEASES,  619 

Diagnosis.  Delusional  mania  and  delusional  melancholia  are 
confounded  with  delusional  insanity,  the  points  of  distinction  beini; 
the  absence  of  severe  maniacal  and  melancholic  acts;  the  patient 
simply  possesses  his  insane  delusion  and  may  never  refer  to  it  unless 
questioned. 

Paranoia  or  monomania  and  delusional  insanity  have  many  symp- 
toms in  common,  but  in  the  former  "  their  whole  thoughts  and  lives 
show  a  strong  self-consciousness,  and  their  egotism  is  intense" 
(Chapin) ;  and  if  the  patient  believes  he  is  Christ,  he  wishes  to  be 
so  respected,  and  considers  himself  wronged  if  not  so  treated,  while 
the  delusional  patient  will  say  he  is  Christ  and  immediately  drop 
the  subject.  There  are,  however,  many  border-land  cases  in  which 
the  diagnosis  is  difficult. 

The  distinction  made  here  between  paranoia  and  primary  delu- 
sional insanity  is  not  generally  accepted. 

Prognosis.  In  acute  primary  delusional  insanity  recovery  is  fre- 
quent, although  the  delusions  may  exist  for  a  number  of  years.  Many 
patients  who  make  a  complete  recovery  will  still  believe  that  their 
delusions  were  facts.  A  fair  proportion  of  cases  pass  into  the  condi- 
tion of  chronic  delusional  insanity,  this  attack  being  the  first  or  second 
period  of  Magnan's  classification,  viz.:  First  period,  incubation  or 
anxiety ;  second  period,  persecution  ;  third  period,  grandeur,  or 
ambition,  or  optimism  ;  fourth  period,  dementia. 

Treatment.  A  supporting  plan  of  treatment,  with  thorough 
action  upon  the  bowels,  kidneys,  and  skin,  and  plenty  of  fresh  air,  is 
of  great  value  in  all  cases  of  delusional  insanity.  If  the  disease  is 
the  result  of  excesses,  a  course  of  strychnina  and  arsenicuni  is  indi- 
cated. A  tranquil  condition  of  the  brain  is  essential,  and  few  com- 
binations are  so  valuable  as  digitalis  and  hyoscina,  in  small,  repeated 
doses.  Insomnia  is  an  annoying  symptom  in  many  cases,  and  is  best 
overcome  by  a  digestible  meal  at  bed-time,  or  a  warm  or  hot  bath  in 
the  evening,  and  if  these  fail  a  full  dose  of  sotnnal  [R.  Somnal,  3"] 
(i2  Cc.) ;  glycerini,  f^ss  (i6  Cc.) ;  tinct.  cardamom,  comp.,  f3ss 
(i6  Cc.)  ;  aquae  menthse  pip.,  ad  f5iij  (90  Cc).  M.  SiG. — Half-table- 
spoonful,  repeated  in  two  hours],  well  diluted,  or  trional,  gr.  xxx 
(2  Gm.),  an  hour  before  bed-time,  in  milk  or  spirits. 


620  PRACTICE    OF    MEDICINE. 


PARANOIA. 


Synonyms.     Monomania  ;  chronic  delusional  insanity  :  reason- 

ing  mania  ;  Veriiicktheit. 

Definition.  A  chronic  mental  disease  characterized  by  fixed 
logical  or  systematized  delusions  of  persecution,  unseen  or  impossible 
agencies,  or  of  self-exaltation,  the  emotions  and  memory  being  only 
paroxysmally  defective,  while,  however,  the  life  of  the  individual  is 
dominated  by  the  delusions. 

The  term  paranoia  is  now  commonly  used  to  cover  a  group  of 
insanities  which  are  degenerative  in  origin,  chronic  in  course,  and 
characterized  by  systematized  delusions,  with  little  impairment  of 
the  emotional  faculties,  and  is  not  generally  accepted  as  a  synonym 
for  monomania. 

"A  primary  developmental  insanity."  "  A  condition  of  degener- 
acy." "  There  is  imbecility  of  mind  and  there  are  delusions " 
(Dewey). 

Causes.  There  is  generally  a  hereditary  predisposition  to  insanity 
in  monomania  or  paranoia.  The  exciting  cause  may  be  the  result  of 
an  acute  mania  or  melancholia,  or  the  result  of  alcoholism,  or  the 
result  of  malnutrition  in  those  who  have  had  a  struggle  to  keep  their 
position  in  the  world.  Extreme  worry  in  individuals  with  mental  in- 
stability.    Following  primary  or  acute  delusional  insanity. 

Symptoms.  The  course  of  monomania  is  essentially  chronic, 
the  delusions  becoming  perfectly  fixed  and  unchanging  upon  one 
particular  subject,  or  set  of  subjects,  which  in  turn  dominate  the  life 
of  the  individual.  The  most  common  characters  of  these  systematized 
delusions  are  delusions  of  persecution  or  suspicion,  delusions  of  exal- 
tation or  of  pride,  and  delusions  of  unseen  agents  or  i?tfluences. 

A  delusion  of  persecution  is  shown  in  a  woman  of  average  talents 
and  education,  who  has  devoted  much  time,  thought,  and  worry  to  a 
number  of  worthless  patents,  and  now  that  she  is  in  an  insane  asylum 
believes  she  has  been  placed  there  that  others  may  reap  the  rewards 
of  her  inventive  genius  ;  she  is  constantly  annoyed  by  what  the 
physicians,  attendants,  and  patients  are  doing,  claiming  that  many 
such  acts  are  for  the  purpose  of  annoying  or  harming  her,  her  sus- 
picions being  of  the  most  aggravating  character. 

Delusion  of  exaltation  or  pride  is  well  shown  in  the  case  of  a  man 
who  believes  he  is  Jesus  Christ,  and  is  angered  almost  to  the  point  of 


MENTAL   DISEASES.  521 

homicide  if  great  consideration  is  not  shown  him.  Another  male, 
whose  origin  is  from  the  lower  walks,  believes  he  is  to  marry  a  distin- 
guished authoress,  and  will  resent  any  doubt  of  his  purpose  with  blows. 

Delusion  of  unseen  age7icies  is  well  shown  in  the  case  of  a  female, 
aged  forty  years,  who  labored  under  the  delusion  that  she  was  beset 
by  numerous  devils  in  her  abdomen,  the  real  cause  being  the  presence 
of  a  cancer  of  the  liver.  Patients  complain  of  electrical  influences, 
telephonic  communications,  and  invisible  agents  tormenting  them. 

The  range  the  delusions  of  monomania  assume  are  most  wide  and 
varied,  but  always  associated  with  the  ego.  The  patient  is  being  per- 
secuted not  because,  as  in  melancholia,  he  has  committed  some  sin, 
or  thinks  he  has,  and  deserves  punishment,  but  because  the  perse- 
cutors wish  to  deprive  him  of  his  rights,  titles,  or  estate,  or  degrade 
him  or  in  some  way  injure  him. 

DiagTlOSis.  In  the  diagnosis  of  monomania  there  are  three  points 
to  ever  keep  in  mind  -.first,  the  duration — the  fixed,  systematized  de- 
lusions must  have  existed  over  one  year;  second,  the  absence  of 
symptoms  of  mania  or  melancholia  ;  and  third,  the  presence  of  sys- 
tematized delusions  affecting  the  personnel  of  the  individual. 

Prognosis.  Monomania  is  an  incurable  disease.  Unless  tuber- 
culosis develop  within  a  few  years,  dementia  results. 

Treatment.  Symptomatic,  and  all  means  that  promote  con- 
structive metamorphosis. 


GENERAL  PARALYSIS. 

Synonyms.  General  paresis  ;  general  paralysis  of  the  insane ; 
paresis  ;  paretic  dementia. 

Definition.  A  subacute  or  chronic,  degenerative  disease  of  the 
brain,  sometimes  involving  the  spinal  cord  ;  characterized  by  altera- 
tions in  the  intellectual  and  moral  character,  with  the  development 
of  unsystematized  ideas  of  self-importance  or  delusions  of  grandeur, 
finally  merging  into  dementia  (preceded  by  either  a  mania  or  a 
melancholia),  and  the  gradual  development  of  tremor,  slurring  speech, 
pupillary  changes,  ataxia,  tropliic  changes,  and  finally  paresis. 

Causes.  General  paralysis  of  the  insane  occurs  chiefly  between 
thirty  and  fifty-five  years  of  age,  and  in  the  male  more  frequently 
than  in  the  female,  although  a  notable  increase  in  the  lower  class  of 


522  VRACTICE    OF    MF.[)ICINE. 

females  is  being  observe^.  It  usually  affects  the  robust,  middle-aged 
individual,  rapidly  destroying  all  intelligence  and  judgment,  leaving 
him  to  exist,  often  for  months,  as  a  demented  human  automaton. 

General  paresis  is  increasing,  and  some  one  has  said  its  increase  is 
in  proportion  to  "  syphilization  and  civilization." 

Predisposing  causes:  Heredity;  an  ambitious  overstraining  for 
prominence,  learning,  or  wealth  ;  forced  intellectual  activity  in  those 
with  imperfect  or  improper  early  training;  or  in  those  with  an  imper- 
fectly developed  or  organized  cortex  ;  cranial  injuries  ;  atheroma. 

^xr/V/«^ £"a«j<r^ .•  Alcoholic  and  sexual  excesses  ;  syphilis;  mental 
and  physical  overstrain  ;  worry.  "  In  many  cases  I  think  the  middle- 
aged  general  paralytic  is  suffering  for  the  sins  of  his  youth  "  (Clouston). 

"  General  paralysis  is  not  a  penalty  of  high  cerebral  develop- 
ment, but  the  expression  of  a  discrepancy — an  inadequacy  of  some 
brains  to  sustain  the  strain  to  which  the  race,  as  a  whole,  is  sub- 
jected "  (Spitzka). 

Pathological  Anatomy.  A  condensed  description  of  the 
pathological  basis  of  general  paralysis  is  difficult.  It  may  be  de- 
scribed as  a  chronic,  diffuse,  cortical  encephalitis.  The  microscopical 
changes  in  the  cortex,  according  to  Mendel,  as  quoted  by  Folsom,  are 
as  follows  : 

1.  Increase  of  nuclei  and  new  cell  formation,  some  nuclei  small, 
some  large,  and  with  such  varying  reactions  to  coloring  agents  as  to 
suggest  dissimilarity  of  origin.  The  stellate  or  "  spider  "  cells  are 
increased  in  the  upper  layer  of  the  cortex,  where  some  may  be  nor- 
mally'found,  and  extend  to  lower  layers,  as  is  not  the  case  in  normal 
brains  ;  they,  too,  may  be  several  times  the  usual  size  and  also  push 
through  the  white  substance  to  the  ependyma  of  the  ventricles.  Pro- 
liferation of  neuroglia  or  connective  tissue,  and  in  time  sclerosis  of 
the  cortex,  which  involves  the  medullary  substance  also  in  a  greater 
or  less  degree. 

2.  The  larger  blood-vessels  may  or  may  not  be  atheromatous ;  in 
the  capillaries  there  is  an  increase  of  nuclei  in  the  walls,  with  thicken- 
ing and  hyaloid  degeneration. 

3.  In  the  nerve-cells,  the  ganglion-cells,  granular  and  fatty  degen- 
eration of  protoplasm,  sclerosis,  atrophy. 

4.  Atrophy  and  final  disappearance  of  the  nerve-fibers,  not  limited 
to  the  cortex  and  found  in  other  brain  diseases  also — senile  dementia 
and  epilepsy,  for  instance. 


MENTAL   DISEASES.  523 

5.  Focal  lesions  of  the  most  various  kinds,  and  degenerative 
changes  in  the  spinal  cord,  the  several  forms  of  sclerosis  and  mye- 
litis. 

The  spinal  cord  undergoes  atrophy  with  gray  degeneration  in  pos- 
terior and  postero-median  columns,  and  of  posterior  spinal  nerve- 
roots. 

Symptoms.  For  clinical  convenience  the  disease  is  divided  into 
three  stages — prodromal,  maniacal,  rarely  melancholic,  and  the  stage 
of  dementia — although  there  is  seldom  a  marked  division  between  the 
stages. 

Prodromal  stage  may  exist  unrecognized  for  months  or  longer.  It 
begins  by  an  alteration  in  the  habits  and  character  of  the  individual, 
such  as  spells  of  irritability  and  obstinacy,  which  will  not  admit  of 
contradiction  or  opposition,  and  there  is  a  general  feeling  of  elation 
and  bien-etre,  or  egotism,  shown  by  the  exalted  opinion  of  his  own  at- 
tainments and  importance,  and  a  great  laudation  of  members  of  his 
family.  He  becomes  boastful,  untruthful,  dishonest,  and  forgetful, 
neglecting  engagements,  business,  self,  and  family.  He  frequently 
makes  extravagant  purchases  and  may  waste  large  sums  of  money 
before  his  condition  of  irresponsibility  is  recognized,  or  may  unwit- 
tingly resort  to  dishonest  means  to  obtain  money,  as  was  shown  in  the 
case  of  an  intelligent  gentleman,  who  had  squandered  considerable 
money  in  unprofitable  property,  going  to  a  railroad  ticket-office,  ask- 
ing for  a  ticket,  remarking  he  was  without  cash,  writing  a  check  for 
one  hundred  dollars  on  a  bank  he  had  never  had  an  account  with, 
receiving  ninety-nine  dollars  in  change,  immediately  going  to  a 
jewelry  store  and  purchasing  a  lady's  gold  watch  and  chain,  paying 
sixty  dollars  for  the  same,  and  then  going  to  a  pawnbroker's  and 
pledging  the  watch  and  chain  for  forty  dollars,  and  the  following  day 
going  to  the  same  ticket-office  and  buying  another  ticket,  such  as 
he  had  purchased  with  the  fraudulent  check,  and  on  being  arrested 
protested  he  had  done  nothing  dishonest. 

In  many  instances  the  patient  develops  ideas  of  an  enterprising 
character,  and  resorts  to  all  forms  of  expedients,  which,  to  his  mind, 
are  going  to  improve  his  or  his  family's  station  and  worldly  condition. 
He  determines  to  change  his  occupation  or  business,  or  attempts  to 
instruct  the  authorities  in  what  he  conceives  should  be  their  duties. 

The  moral  lapses  of  paretics  are  most  frequent  during  this  stage, 
consisting  of  acts  of  theft,  drunkenness,  violent  impulses,  or  indecent 


524  PRACTICE    OF    MEDICINE. 

assaults,  in  individuals  who  have  possessed  a  good  moral  character. 
They  become  profane  and  vulgar,  and  often  resort  to  sexual  excesses. 
Associated  with  any  of  the  above  symptoms  may  be  any  one  or  more 
of  the  following  physical  conditions  :  tremor  of  the  muscles  about  the 
tnoulh,  naso-labial  folds,  and  of  the  tongue,  causing  a  slight  slur  or 
Ju'sidxting  speech  ;  alterations  in  the  pupils,  or  one  pupil  becoming 
somewhat  larger  than  the  other,  or  the  pupils  may  be  contracted  to 
pin-head  size  with  loss  of  accommodation  ;  attacks  of  vertigo,  or  epi- 
leptiform or  apoplectiform  seizures.  The  gastric,  intestinal,  hepatic, 
and  nephritic  secretions  are  disturbed,  and  there  may  be  headache 
and  insomnia.  After  a  variable  duration,  continuing  in  a  mild  degree 
for  many  months,  is  ushered  in  the — 

Second  or  maniacal  stage,  which  is  much  the  same  as  a  severe 
attack  of  acute  mania  (megalomania), //«^  the  physical  signs  of  par- 
esis and  the  delusions  or  ideas  oi grandeur.  The  patient  is  excessively 
restless,  boasting  of  his  great  wealth,  intentions,  prospects,  and  influ- 
ence ;  one  moment  the  most  important  of  individuals,  the  next  giving 
away  thousands,  and,  if  doubt  is  expressed  as  to  his  ability  to  do  so, 
making  it  millions  and  often  billions;  presenting  houses  and  lands, 
titles  and  offices,  with  unstinted  liberality.  It  is  to  be  noted  that  these 
so-called  delusions  of  the  paretic  are  in  reality  conceptions,  or  an  ex- 
pansive delirium,  for  when  contradicted  the  patient  makes  no  effort 
to  defend  them ;  they  seem  to  be  really  assertions  and  reassertions, 
continuing  until  incoherency  restrains  the  airy  imagination.  If  ques- 
tioned as  to  his  health,  replies,  enthusiastically,  "  First-rate ;  never 
better  in  my  life."  The  patient  is  sleepless,  noisy,  destructive,  with 
attacks  of  blind,  uncalculaling  violence,  resisting  all  who  attempt  to 
restrain  or  molest  him.  The  violent  impulses  of  paretics  are  similar 
to  the  furious  excitement  of  the  post-epileptic  maniac. 

The  physical  signs  are  more  pronounced  :  the  characteristic  hesitat- 
ing and  slurring  speech  increases  ;  the  pupillary  changes  become 
more  marked  ;  the  tremor  of  the  tongue  and  lips  increasing  and 
spreading  to  the  upper  extremities  ;  i\\G  gait  ataxic  ;  \\\e  patellar  reflex 
increased,  or,  rarely,  diminished ;  the  sphincter  of  the  bladder  disor- 
dered, and  there  sometimes  occurs  paralysis  of  the  anal  sphincters. 

During  the  progress  of  the  second  stage  are  developed  cerebral 
crises, — syncope,  petit  or  grand  mal,  apoplectiform  attacks,  or  para- 
lytic seizures.  Few  cases  but  show  one  or  more  of  these  conditions. 
There  also  occurs  mvosis  and  loss  of  light  reaction,  and  increased 


MENTAL   DISEASES.  525 

wrist  and  elbow  jerks.  The  maniacal  stage  is  of  shorter  duration 
than  any  other,  and  is  usually  succeeded  by  the — 

Stage  of  dementia,  the  patient  presenting  all  the  evidences  of  failing 
mentality,  with  paralysis,  trophic  changes,  as  shown  by  the  occur- 
rence oi  bed  sores,  cystitis,  diarrhcea,  and  arthropathies,  or  Charcot's 
joints,  the  patient  emaciating  rapidly,  death  closing  the  scene  within 
a  few  months. 

Rarely  the  maniacal  stage  is  preceded  or  replaced  by  a  condition 
of  melancholia  with  expansive  hypochondriacal  delusions.  In  a  few 
instances  a  genuine  lucid  interval  has  followed  either  the  prodromal 
or  maniacal  stage.  The  spinal  form  of  general  paresis  is  fairly  fre- 
quent, in  which  symptoms  of  spinal  sclerosis  are  added  to  the  mental 
ataxic  phenomena  of  the  usual  form. 

"Of the  many  divisions  of  general  paralysis  into  several  clinical 
types,  all  of  them  naturally  more  or  less  arbitrary,  I  know  no  other  so 
satisfactory  as  Meynert's  eight "  (Folsom)  : 

1.  Simple  progressive  dementia,  with  the  usual  motor  impairment 
which  accompanies  it,  but,  excepting  hypochondriacal  depression,  not 
necessarily  exhibiting  other  mental  symptoms  than  dementia. 

2.  With  the  expansive  delusions  and  the  distinctive  motor  disturb- 
ances, which  appear  simultaneously  and  are  progressive,  constituting 
the  "  classic  "  form  of  general  paralysis.  The  mental  state  is  usually 
of  self-satisfaction  and  exaltation,  but  there  may  be  depression. 

3.  Of  the  same  type  as  the  last,  but  failing  its  steadily  progressive 
character  through  arrest  of  the  active  process.  The  remissions,  which 
seldom  last  so  long  as  a  year,  raise  hopes  of  recovery,  but  still  mani- 
fest unmistakable  impairment  of  the  reasoning  faculties.  The  psychic 
disturbances  are  much  greater  than  can  be  accounted  for  by  the 
atrophy  of  the  brain  alone. 

4.  Cases  in  which  the  characteristic  exaltation  and  grand  delusions 
reach  such  an  astonishing  height  that  manifest  motor  symptoms  are 
looked  for  with  confidence  from  day  to  day,  and  yet  may  not  appear 
even  for  a  year,  any  slight  inco-ordination  naturally  being  obscured 
by  the  general  muscular  disturbance.  Meanwhile  there  may  be  such 
an  improvement  that  the  patient  leaves  the  hospital  for  a  while,  once, 
rarely  twice,  on  the  responsibility  of  his  family,  but  to  return  with 
marked  motor  as  well  as  mental  signs. 

5.  Avery  rare  form,  with  alternate  symptoms  of  exaltation  and  de- 
pression of  the  type  of  circular  insanity. 


52ri  PRACTICE    OF    Mi:niCINE. 

6.  With  early  furious  delirium,  painful  ballucinations,  confusion 
and  incoherence  somewhat  resembling  acute  delirium 

7.  Progressive  general  paralysis,  in  which  the  characteristic  indica- 
tions appear  secondary  to  other  forms  of  insanity  ;  for  instance,  after 
paranoia  or  melancholia,  first  described  by  Hocstermann. 

8.  The  combined  form  with  sclerosis  in  the  whole  cerebro-spinal 
tract,  the  symptoms  of  tabes  or  spastic  paralysis  predominating,  ac- 
cording as  the  posterior  or  lateral  columns  of  the  spinal  cord  are 
chiefly  involved.  The  ascending  type,  in  which  the  cord  is  first 
affected,  is  rare.  Optic  neuritis,  ending  in  atrophy  and  paralysis, 
especially  of  the  ocular  muscles,  may  precede  marked  mental  symp- 
toms. 

Diagnosis.  The  development  of  the  following  symptoms  re- 
moves all  difficulties  in  diagnosis:  Mental — alteration  in  character, 
loss  of  memory,  defective  will-power,  changed  moral  sense,  insomnia, 
violent  impulses,  melancholia  or  mania,  unsystematized  delusions  of 
expansive  character,  with  an  exalted  sense  of  well-being,  gradually 
ending  in  dementia.  Physical — hesitating,  slurring  speech;  tremor 
of  the  lips,  tongue,  and  upper  extremities  ;  pupillary  changes,  myosis, 
loss  of  light  reaction;  exaggerated  wrist-,  elbow-,  and  knee-jerk; 
attacks  of  syncope,  vertigo,  epileptiform  or  apoplectiform  seizures, 
ataxia,  trophic  changes,  and  finally  paralysis. 

Paralytic  insanity,  organic  dementia,  or  dementia  paralytica,  is  not 
the  same  condition  as  general  paralysis.  It  is  the  form  of  mental 
failure  succeeding  to  gross  brain  lesions,  such  as  apoplexy,  tumors, 
softening,  trauma,  and  sclerosis,  associated  with  either  hemiplegia  or 
paraplegia. 

Prognosis.  Unfavorable.  Remissions  very,  very  rarely  occur. 
The  duration  of  general  paresis  has  been  considerably  lengthened 
by  the  hospital  care  of  such  patients  now  in  vogue  in  all  properly 
conducted  insane  hospitals. 

Treatment.  The  care  of  the  general  health  and  meeting  symp- 
toms as  they  arise  is  all  that  can  be  done  for  general  paresis.  It 
is  claimed  that  if  the  condition  be  recognized  early  in  the  prodromal 
stage,  the  stage  of  cerebral  congestion  or  vasomotor  paresis,  much 
good  may  be  accomplished,  and,  if  not  cured,  may  be  held  in 
check  for  a  long  period  of  time  by  the  use  of  such  drugs  as  digitalis 
or  ergoia. 

The  maniacal  excitement  may  be  quieted  by  the  use  of  the  hot  bath, 


MENTAL   DISEASES.  527 

isolatiojt  (not  seclusion),  and  the  administration  of  small  doses  of 
hyosctnce  hydrobromas,  which  seems  to  exert  an  alterative  action  on 
the  brain.  For  the  insomnia,  irional,  gr.  xx-xxx  (1.3-2  Gm.),  re- 
peated, is  usually  satisfactory. 

If  a  reliable  syphilitic  history  is  obtained,  a  thorough  course  of 
hydrargyrum  and  iodides  should  be  administered.  All  means  that 
promote  the  constructive  metamorphosis  are  indicated  in  this  most 
characteristic,  progressive  malady. 

DEMENTIA. 

Synonym.     Acquired  feeble-mindedness. 

Definition.  A  progressive  general  weakening  of  the  mind,  char- 
acterized by  a  loss  of  reasoning  capacity,  a  diminution  of  feeling,  a 
weakened  volitional  and  inhibitory  power,  failure  of  memory,  asso- 
ciated with  lack  of  the  power  of  attention,  interest,  and  curiosity,  in 
varying  degrees,  in  an  individual  who  at  one  time  possessed  these 
mental  qualities. 

Forms.  Acute  dementia  ;  alcoholic  demetitia  ;  de?nentia  apoplec- 
tica  or  paralytica ;  dementia  choreica ;  chronic  or  secondary  de- 
mentia ;  dementia  epileptica  ;  organic  dementia  ;  partial  dementia  ; 
primary  dementia  ;  dementia  senilis  ;  dementia  syphilitica  ;  dementia 
toxica. 

Causes.  Deficient  or  feeble  mental  inheritance ;  age  ;  atheroma ; 
following  mania,  melancholia,  paranoia,  and  other  forms  of  insanity  ; 
the  result  of  organic  brain  conditions  ;  alcoholism  ;  syphilis  ;  devel- 
opmental changes  ;  climacteric. 

Pathology.  In  acute  dementia  the  changes  are  dynamic.  In 
the  primary  dementia  there  is  probably  atrophy  of  certain  cells  from 
overstimulation,  the  tissues  being  normally  deficient.  In  secondary 
dementia  the  chief  changes  are  :  "alteration  in  the  size  of  the  vessels, 
owing  to  thickening  and  distention,  the  thickening  being  most  marked 
in  the  deep  layers,  and  in  the  walls  of  the  vessels  are  fatty  granules 
and  hasmatoidin.  The  perivascular  canals  are  enlarged.  The  changes 
in  the  cells  may  be  described  as  deficiency  in  the  number  of  pyra- 
midal cells,  and  a  want  of  distinctness  of  outline  and  branches,  the 
nuclei  being  larger,  but  changed  in  form,  and  only  capable  of  slight 
carmine  staining."  In  senile  dementia  there  is  general  atrophy  and 
degeneration  of  all  the  tissues  of  the  brain, 


528  PRACTICK    OF    MEDICINE. 

Symptoms.  The  onset,  extent,  and  v.nriety  of  the  impaired 
mcnt.ilily  differ  greatly.  In  some  patients  the  evidences  of  the  fail- 
ing mind  are  seen  with  the  subsidence  of  the  mania,  melancholia,  or 
other  insanity,  or  soon  after  the  development  of  the  particular  cause, 
while  in  another  group  of  cases  the  development  is  slow  and  insidious. 
The  difference  in  the  intensity  is  marked;  in  one  case  the  changes 
being  scarcely  noticeable,  the  patient  being  simply  less  active  than 
before,  showing  a  slight  indifference  to  his  environment;  while  in 
others  the  patients  remain  for  hours  alone,  making  no  effort  at  move- 
ment and  with  little  or  no  expression  of  the  face  ;  while  another  class 
of  cases  are  oblivious  to  the  demands  for  food  or  drink,  or  the  calls 
of  nature,  existing  "  in  the  darkness  of  perpetual  intellectual  and 
moral  night."  Between  these  symptoms  are  all  varieties  and  degrees 
of  mental  enfeeblement,  \\\t.  physical  syvipioms  of  dementia  varying 
with  the  particular  cases,  many  enjoying  the  best  of  health,  eating  and 
sleeping  well ;  while  others  are  always  unwell,  first  one  organ  and  then 
another  being  affected ;  while  another  group  suffer  from  chronic 
diarrhoea,  which  finally  causes  death.  Dementia  patients  seem  pre- 
disposed to  tuberculosis,  nephritis,  and  epilepsy. 

Acute  dementia,  or  "  stupor  with  dementia,"  is  to  be  distinguished 
from  "  stupor  with  melancholia."  The  onset  is  rather  sudden,  with 
or  without  mania  or  melancholia,  after  some  brain  or  bodily  exhaus- 
tion, shock,  or  fright ;  the  patient,  a  young  person,  "  is  horror-stricken, 
paralyzed  in  mind,  not  merely  deranged,  not  depressed  or  excited,  but 
deprived  of  feeling  and  intellect ;  his  movements,  if  there  be  any,  are 
automatic,  but  frequently  he  is  motionless,  standing  or  sitting,  staring 
at  vacancy  for  hours  and  days  "  (Blandford).  These  patients  will 
not  converse,  and  do  not  reply  to  questions,  or  but  slowly,  and  in 
monosyllables,  and  their  faces  have  a  blank  expression.  One  young 
man  of  twenty-three  years,  but  three  years  in  America,  having  an 
excellent  musical  education  and  remarkable  skill  as  a  piano  per- 
former, being  unable  to  secure  pupils  to  instruct,  was  obliged  to 
accept  a  position  as  a  piano-player  at  a  questionable  summer-resort 
garden,  where  he  contracted  the  alcoholic  and  sexual  habit.  His 
excesses  increased,  although  never  intoxicated ;  he  suddenly  de- 
veloped symptoms  of  dementia,  his  mind  becoming  a  complete 
blank,  his  circulation  feeble,  the  surface  cold  ;  and  he  never  offered 
to  enter  the  dining-room,  and  yet  attended  to  the  calls  of  nature. 
He  never  spoke,  and  would  remain  alone  and  motionless  for  hours. 


MENTAL    DISEASES.  529 

The  sweetest  music  caused  no  movement  showing  inteUigence.  He 
was  placed  on  the  Mitchell  rest  treatment  for  six  weeks,  and,  as  his 
bodily  condition  improved,  he  was  daily  taken  to  the  piano,  and  his 
fingers  made  to  touch  the  keys.  For  weeks  he  showed  no  interest, 
when,  slowly,  one  day  he  feebly  ran  his  fingers  over  the  keys,  and 
from  that  day  improved,  until,  within  four  weeks,  his  performance  on 
the  piano  attracted  wide  attention,  and,  after  recovery,  which  was 
complete,  with  no  recollection  of  this  sickness,  he  secured  pupils  and 
is  to-day  a  successful  teacher.  He  has  assured  me  that  he  suffered 
no  pain,  no  depression,  but  that  all  is  a  blank  to  him. 

Alcoholic  dementia,  the  mental  weakness  resulting  from  excessive 
use  of  alcohol.  Inebriety  is  a  form  of  dementia,  there  existing  an 
uncontrollable  alcoholic  habit,  with  weakened  or  absent  will  power 
and  impaired  mentality,  Sutherland  defines  seven  forms  of  insanity 
from  alcoholic  excess:  (i)  Intoxication;  (2)  delirium  tremens ;  (3) 
mania-a-potu  ;  (4)  dipsomania ;  (5)  mania  of  suspicion  ;  (6)  chronic 
alcoholism  or  dementia  ;  (7)  general  paralysis. 

Dementia  apoplectica  or  paralytica  is  an  organic  or  terminal  de- 
mentia due  to  the  cerebral  changes  sometimes  following  a  severe 
apoplectic  seizure,  and  is  usually  associated  with  hemiplegia. 

Dementia  choreica  is  a  feeble-mindedness  associated  with  chronic 
or  hereditary  chorea,  or,  in  some  cases,  probably  the  result  of  chorea. 

Chronic  dementia  is  the  designation  applied  to  all  forms  of  dementia 
that  have  existed  after  one  or  more  years. 

Dementia  epileptica  is  the  slow  mental  irhpairment  resulting  from 
long-continued  and  frequently  occurring  epileptic  convulsions. 

Organic  dementia,  the  mental  deterioration  resulting  from  gross 
organic  brain  lesions,  such  as  sclerosis,  tumor,  embolism,  or  trauma. 
An  intelligent  machinist,  aged  forty  years,  fell  a  distance  of  twenty 
feet,  striking  on  his  head,  but  not  causing  any  determined  fracture. 
He  was  unconscious  one  week,  and  on  slowly  recovering  it  was  no- 
ticed that  there  was  some  change  of  character,  which  has  grown 
most  decided,  and  is  associated  with  persistent  insomnia.  He  is  rest- 
less, indifferent ;  has  loss  of  memory,  is  vulgar  and  profane,  and  in- 
clined to  be  talkative — opposite  traits  to  his  former  self;  has  violent 
outbreaks,  and  has  a  delusion  that  he  is  to  make  a  fortune  out  of  a 
polish  the  formula  for  which  was  given  him  by  God,  but  which  he 
has  mislaid.  He  cannot  read  or  write,  or,  at  least,  he  will  never  make 
the  attempt.  His  physical  condition  is  good, 
34 


f)30  PRACTICE    OF    MEDICINE. 

Partial  dcmetttia  is  an  incomplete  form  of  dementia  in  which  the 
mental  enfeeblement  is  associated  with  such  a  degree  of  intelligence 
and  memory  that  the  qualifying  term  "  partial  "  is  correct.  This 
variety  of  dementia  constitutes  the  majority  of  able-bodied,  working, 
chronic  insane  patients  seen  in  insane  hospitals. 

Primary  dementia  is  seen  most  frequently  in  the  young,  developing 
slowly  and  insidiously,  without  any  symptoms  of  mania  or  melan- 
cholia, usually  in  a  youth  who  has  given  promise  of  a  bright  future, 
by  a  slowly  progressive  indifference  to  his  former  occupation,  studies, 
or  surroundings,  with  developing  carelessness  and  negligence  of  per- 
son and  proprieties,  no  amount  of  external  stimulus  serving  to  rouse 
the  receding  mentality,  until  finally  the  downward  course  ends  in 
dementia  so  decided  that,  but  for  the  history  of  the  individual,  the 
case  would  be  classed  as  congenital,  or  imbecility. 

Secondary,  sequential,  or  chronic  dementia,  is  the  most  common 
variety  of  mental  impairment  following  mania,  melancholia,  and  other 
insanities.  According  to  Bevan  Lewis,  twenty  per  centum  of  manias 
and  fifteen  per  centum  of  melancholias  become  permanent  dements. 

Dementia  seiiilis,  the  result  of  cerebral  atrophy,  with  its  consequent 
failing  mental  power.  Loss  of  memory  for  recent  events  is  one  of  the 
most  common  symptoms.  The  disease  often  begins  as  a  senile 
mania,  melancholia,  or  delusional  insanity.  A  female  aged  sixty 
years,  with  intemperate  history,  was,  on  admission,  exceedingly  filthy 
and  with  many  vermin.  She  says  she  has  been  persecuted  in  her 
poverty  ;  that  she  could  not  obtain  goods  from  the  store  when  she  had 
no  money,  though  the  shopkeeper  was  rich  ;  that  she  was  neglected 
by  others ;  insists  that  she  ought  to  have  been  assisted  ;  is  uncon- 
cerned with  her  surroundings ;  is  trifling  and  disrespectful,  restless, 
moving  her  hands  and  body  almost  continually  ;  is  childish  and  silly 
in  manner,  frequently  laughing,  claiming  she  is  happy,  and  will  not 
work;  cannot  remember  her  only  sister's  name  or  where  she  herself 
last  resided. 

Dementia  syphilitica  is  the  feeble-mindedness  resulting  from  cere- 
bral syphilis.  This  group  of  patients  are  always  sanguine,  and  assert 
they  are  "  all  right,"  "never  sick  in  my  life,"  and  yet  unable  to  assist 
or  care  for  themselves.  This  form  of  dementia  has  many  symptoms 
akin  to  general  paresis,  and,  indeed,  is  often  termed  "pseudo- 
paresis." 

Dementia   toxica   is   the   mental    failure   produced   by   the   long- 


DISEASES   OF  THE  SKIN.  531 

continued  and  excessive  use  of  opium,  cocaine,  and  chloral.  Chronic 
plumbism  is  also  given  as  a  cause. 

Diagnosis.  Acute  dementia  is  often  misnamed  melancholia  with 
stupor,  but  if  the  patient  is  in  the  teens  the  probabilities  are  that  it  is  a 
case  of  the  former,  while  if  past  forty  it  is  almost  certainly  the  latter. 

The  distinction  between  dementia  and  idiocy  or  imbecility  must 
always  be  determined.  Esquirol's  graphic  description  is  well  worth 
remembering  :  "  The  dement  was  a  rich  man  who  has  become  poor  ; 
the  idiot,  on  the  contrary,  has  always  been  in  a  state  of  want  and 
misery." 

Prognosis.  Acute  dementia  is  generally  favorable.  All  other 
varieties  are  incurable.  The  average  life-time  of  dements  is  placed  at 
about  twelve  years,  the  great  majority  dying  of  tuberculosis,  nephritis, 
or  apoplexy. 

Treatment.  Patients  suffering  from  acute  dementia  should  be 
placed  on  the  Mitchell  rest  regime,  with  attention  to  all  the  secretions. 
If  Dr.  Mitchell's  directions  are  carefully  followed,  the  great  majority 
of  cases  of  acute  dementia  will  recover  within  nine  to  twelve  months. 

For  the  other  forms  of  dementia,  unfortunately,  there  is  no  cure, 
the  treatment  resolving  itself  into  attention  to  the  general  health,  with 
proper  custodial  oversight. 


DISEASES  OF  THE  SKIN. 


DISORDERS    OF  SECRETION. 

SEBORRHOEA. 

Synonyms.  Acne  sebacea ;  pityriasis  ;  tinea  furfuracea ;  dandruff. 

Definition.  A  functional  disorder  of  the  sebaceous  glands  of  the 
skin;  characterized  by  an  excessive  or  diminished  and  abnormal 
secretion  of  sebaceous  matter,  forming  upon  the  skin  either  as  an  oily 
coating  or  in  crusts  and  scales. 

Varieties.     Seborrhcea  oleosa  ;  seborrhoea  sicca. 


532  PRACTICE    OF    MKDICINE. 

Causes.  In  newly  born  infants  an  increased  secretion  of  seba- 
ceous matter — the  7icrnix  caseosa — is  a  physiological  process. 

The  origin  of  the  disease  is  not  fully  understood,  anaemia  being  a 
factor  in  many  cases.  Brunettes  are  more  often  affected  than  blondes, 
and  women  more  frequently  than  men. 

Pathology.  Seborrhoea  is  a  functional  derangement  of  the 
sebaceous  glands;  if  it  be  allowed  to  become  very  chronic,  there 
occurs  atrophy  of  the  glands  and  follicles. 

Symptoms.  The  affection  may  occur  upon  any  portion  of  the 
body,  its  most  frequent  seat  being,  however,  the  scalp  (sebot-rhaa  capitis 
ox  pityriasis  capitis),  and  next  in  {xt<i\Vit.wzy  \\\Q  face  {scborrJia:a  faciei). 

Seborrhea  oleosa  appears  as  an  oily ,  greasy  coating  upon  the  skin, 
without  hyperaemia,  and  not  attended  with  itching.  The  secretion  is 
of  an  oily  character,  the  quantity  at  times  being  so  great  as  to  collect 
in  minute  drops  of  a  clear,  yellowish  fluid  upon  the  surface. 

The  most  common  seat  for  this  variety  is  the  face — seborrhoea  faciei 
— and  nose — seborrhoea  nasi. 

Seborrhasa  sicca  consists  in  the  formation  of  dry,  more  or  less 
greasy,  masses  of  scales  or  crusts  oi  3.  grayish,  yellowish,  or  brownish- 
yellow  color,  having  a  strong  tendency  to  adhere  to  the  skin,  and 
attended  with  decided  itching.  Occurring  upon  the  scalp — seborrhea 
capitis — it  is  a  frequent  source  oi  premature  baldness. 

Diagnosis.  Seborrha:a  capitis  may  be  mistaken  for  dry  eczema, 
but  the  former  is  always  a  dry  disease,  while  in  eczema  moisture  has 
occurred  at  some  period  of  the  affection.  The  scales  in  seborrhoea 
are  very  abundant  and  pale  ;  in  eczema  the  scales  are  scanty  and 
reddish,  the  parts  irritated,  infiltrated,  and  thickened. 

Seborrhaa  sicca  and  psoriasis  have  many  points  of  resemblance, 
whether  occurring  on  the  scalp  or  on  the  body.  In  seborrhoea  the 
scales  are  minute  or  caked,  grayish  or  yellowish  in  color,  of  an 
unctuous  feel,  and  usually  uniformly  diffused.  In  psoriasis  the  scales 
are  very  dry,  abundant,  thick,  white,  irregularly  dispersed,  with  inter- 
vening healthy  skin,  and  the  surface  beneath  the  scales  is  always  reddish 
and  inflamed.     The  clinical  histories  of  each  are  entirely  different. 

F^rognosis.  If  properly  treated,  favorable,  although  the  affection 
is  obstinate  to  eradicate. 

Treatment.  The  secretions  require  attention.  If  anaemia  be 
pr&stnt, ferrum  and  arsenicum  are  indicated.  The  following  formula 
of  Sir  Erasmus  Wilson,  and  lauded  by  Hebra,  is  valuable: 


DISEASES   OF  THE  SKIN.  .     533 

R.     Vini  ferri, f^iss  45-  Cc. 

Syr.  simplicis, 

Liq.  potassii  arsenit.,     .    .    .    aa  f.^ij  aa       8.  Cc. 

Aquas  destil. , f^ij  6o.  Cc.  M. 

SiG. — Teaspoonful  three  times  a  day,  well  diluted. 

Duhring  recommends  calcii  sulphidum,  gr.  xn~i  (0.0065-0.013  Gm.), 
several  times  daily. 

Local  measures  are  the  most  important  in  seborrhoea.  For  sebor- 
rhcea  capitis  the  following  plan  will  usually  be  successful : 

The  scales  are  to  be  thoroughly  moistened  with  either  oleiim  oHvce, 
oleum  morrhucE,  or  adeps,  to  facilitate  their  removal ;  it  is  best  applied 
at  night  and  the  head  covered  with  a  flannel  or  other  cap ;  or  R . 
Liq.  boro-glycerini,  f^ij  (8  Cc.) ;  Aquas  rosse,  f^viij  (240  Cc.) ;  mix  and 
apply  on  gauze.  As  soon  as  the  crusts  are  well  soaked  they  should  be 
removed  by  washing  with  soap  and  warm  water,  or  equal  parts  of 
soap,  glycerine,  and  water,  or  the  following  will  be  found  valuable : 

R.     Tinct.  sapo  mollis, f.?iv  120.  Cc. 

Spts.  vini  rect., f^ij  60.   Cc.  M. 

Solve  et  filtra. 

SiG. — Dilute  and  use  as  a  soap- wash  or  shampoo. 

The  scalp  is  to  be  thoroughly  cleansed  of  either  of  the  above  by 
again  washing  with  warm  water,  and  then  dried  by  means  of  a  soft 
towel.  Then  should  be  applied  some  oily  or  fatty  substance,  depend- 
ing upon  the  condition  of  the  scalp. 

If  much  irritation,  either  vaselinum  or  oleujn  amygdalce  expressunt. 
If  no  irritation  be  present,  a  stimulating  preparation  will  be  found  of 
great  benefit.     Either  of  the  following  may  be  used  : 

R.     Tinct.  cantharidis, f^iij  12.  Cc. 

Tinct.  capsici, f^iij  12.  Cc. 

01.  ricini,     .    , fgij  8.  Cc. 

Alcoholis, f  tij  60.  Cc. 

Spt.  rosmarini, f 5J  30.  Cc.                M. 

— {JDuhring.') 
Or— 

R .     Bismuthi  subnitratis, ^j  4.   Gm. 

Ung.  hydrargyri  ammoniat.,      .    .    ^i]  8.    Gm. 

Ung.  aquas  rosse, ^<i    3J  ^'^  3°-   Gm.  M. 

The  above  should  be  repeated  every  day  or  two,  as  the  symptoms 
may  require,  until  a  cure  is  effected. 


534  PRACTICE    OF    MEDICINE. 

The  boroglyceridum  mixture  mentioned  above  or  the  following  com- 
bination is  useful  for  dandruff: 

It.     Ammonii  hydrochlorat. ,    ....    pr.  x  0.65  Gm. 

Glyccrini, f,^j  30.       Cc. 

Aquoe  rosae, f5v  155.       Cc.             M. 

SiG. — Apply  to  head. 

SeborrhcEa  occurring  on  other  portions  of  the  body  is  to  be  treated 
upon  the  same  general  principles. 


COMEDO. 

Synonyms.     Acne  punctata  nigra  ;  black-heads  or  worms. 

Definition.  A  disorder  of  the  sebaceous  glands;  characterized 
by  retention  in  the  excretory  ducts  of  an  inspissated  secretion  which 
is  visible  upon  the  surface  as  yellowish  or  whitish  pin-point  and  pin- 
head-sized  elevations,  containing  in  their  centres  blackish  points. 

Causes.  The  exact  etiology  is  unknown.  Among  the  causes  as- 
signed are  anaemia,  menstrual  disorders,  urethral  irritations,  dyspep- 
sia, and  constipation. 

Pathologry.  Comedo  is  an  affection  of  the  sebaceous  glands  and 
ducts,  consisting  of  an  accumulation  of  sebum  and  epithelial  cells  in 
the  glands  and  follicles,  dilating  the  ducts  to  such  an  extent  as  to  pro- 
duce the  point  or  elevation  upon  the  surface.  The  obstructed  gland 
may  relieve  itself,  or  it  may  continue  distending  until  a  papule  is 
formed.  The  duct  sometimes  contains  small  hairs,  and  also  the 
microscopic  mite,  demode x  folliculorum, — having  a  length  of  from 
TSTT  ^^  yV  '^^  ^"^  inch,  and  breadth  of  about  t^J^  of  an  inch, — which 
was  at  one  time  supposed  to  be  the  cause  of  the  affection. 

Symptoms.  A  chronic  affection,  observed  for  the  most  part 
on  the  face,  neck,  chest,  and  back.  Each  elevation  or  black- 
head or  point  is  designated  a  comedo  ;  if  a  number,  comedones. 

Each  comedo  is  small,  varying  from  a  pin-point  to  a  pin-head  in 
size,  having  a  brownish  or  blackish  appearance,  from  the  dust  or  dirt 
that  has  adhered  to  the  unctuous  surface.  If  they  form  in  great 
numbers  upon  the  face  they  are  disfiguring,  giving  the  individual  the 
appearance  of  having  had  minute  grains  of  powder  implanted  in  the 
skin.  There  are  no  evidences  of  inflammation  unless  acne  is  asso- 
ciated, but,  on  the  contrary,  the  skin  has  a  dirty,  greasy,  unwashed 
appearance. 


DISEASES   OF   THE  SKIN.  635 

Diagnosis.  There  is  no  condition  resembling  comedo,  so  that  its 
recognition  is  easy,  unless  complicated  with  acne ;  but  even  then  the 
inflammatory  appearance  of  acne  should  prevent  error. 

ProgTlosis.     Favorable,  although  often  remarkably  obstinate. 

Treatment.  Derangement  of  any  of  the  functions  of  the  body 
should  be  corrected,  and  strict  attention  be  given  to  the  rules  for  pro- 
moting the  general  health. 

Local  mesisures  are  usually  sufficient.  The  parts  should  be  thor- 
oughly softened  by  bathing  with  soap  and  warm  water,  when  the 
comedones  are  removed  by  friction  with  a  Turkish  towel,  pressure 
between  the  thumb-nails,  the  application  of  a  watch-key,  or  the  in- 
strument known  as  the  "  comedo  extractor,"  and  their  return  pre- 
vented by  an  ungiientum  medicated,  to  meet  the  indications,  with 
either  sulphur,  alkalies,  or  hydrargyrum. 

Dr.  Shoemaker  recommends  the  following  formula: 

R .     Thymol,       gr-  X  0.65  Gm. 

Acidi  borici, 2  ij  8.       Gm. 

Aquse  hamamel.  Virg.  dest.,     .    .  f.^iv  15.       Cc. 

Aquae  rosse, f  Jj  30.       Cc. 

SiG. — Mop  well  over  the  surface  once  or  twice  daily. 


MILIUM. 

Ssmonyms.  Grutum  ;  tubercula  miliaria  or  sebacea  ;  acute  punc- 
tata albida. 

Definition.  An  accumulation  of  sebum  in  the  sebaceous  glands 
which  are  minus  their  excretory  ducts  ;  characterized  by  the  forma- 
tion of  small,  roundish,  whitish,  sebaceous,  non-inflammatory  eleva- 
tions, situated  immediately  beneath  the  epidermis. 

Cause.     The  origin  of  the  affection  is  not  understood. 

Pathology.  The  sebaceous  gland  is  distended  with  the  sebum, 
which  is  unable  to  escape,  owing  to  the  obliteration  of  the  duct,  nor 
can  the  contents  be  squeezed  out,  as  no  sign  of  aperture  is  to  be 
found,  the  formation  being  completely  enclosed. 

Rarely  the  retained  secretion  undergoes  a  metamorphosis  into  hard, 
calcareous,  stone-like  masses — sebaceous  concretions  or  ctitaneous 
calculi. 

Symptoms.  Milia  may  occur  upon  any  portion  of  the  body ; 
their  usual  seat,  however,  is  upon  the  face,  forehead,  and  about  the 


53G  PRACTICE    OF    MEDICINE. 

eyes.  They  form  gradually,  are  about  the  size  of  a  millet  seed,  of  a 
whitish,  pearl,  or  yellowish  color,  hard,  and  of  a  rounded  shape,  giv- 
ing the  sensation  to  the  touch  of  hard  bodies  embedded  in  the  skin. 
They  are  not  associated  with  inflammatory  symptoms. 

Diagnosis.  Milium  and  comedo  are  somewhat  similar  in  ap- 
pearance; the  differences  are  that  in  milium  the  sebaceous  gland  is 
ilistended  without  an  opening,  while  in  comedo  the  duct  of  the  gland 
is  always  patulous  upon  the  surface.  Milium  usually  exists  singly, 
the  skin  looking  normal ;  while  comedo  is  more  general,  the  surface 
having  a  soiled  and  greasy  appearance. 

Prognosis,     Favorable. 

Treatment.  As  a  rule,  no  treatment  is  needed,  the  number  being 
few  and  their  presence  of  no  consequence. 

If  their  removal  be  desirable,  two  modes  suggest  themselves  :  one, 
to  open  the  cyst  with  a  fine-bladed  bistoury,  and  turning  the  contents 
out,  destroying  the  remaining  sack  by  the  application  of  either  tinc- 
itira  iodi  or  acidum  chromici ;  or  the  cyst  may  be  destroyed  by 
electrolysis. 

SEBACEOUS  CYST. 

Synonyms.     Wen  ;  sebaceous  tumor ;  encysted  tumor. 

Definition.  A  distention  of  the  sebaceous  gland  and  duct,  with 
hypertrophy  of  the  walls,  forming  a  thick,  tough  sac  or  cyst:  char- 
acterized by  a  firm  or  soft,  more  or  less  rounded  tumor,  having  its  seat 
in  the  skin  or  subcutaneous  connective  tissue. 

Cause.     Unknown. 

Pathology.  Hypertrophy  of  the  gland  and  duct  walls,  the  result 
of  pressure  from  the  accumulated  contents,  which  consist  of  the 
altered  products  of  the  sebaceous  secretion. 

Symptoms.  The  development  of  wens  is  slow  and  insidious. 
The  localities  where  they  are  most  commonly  developed  are  the  scalp, 
face,  back,  and  scrotum. 

The  tumors  occur  singly  or  in  numbers,  in  size  from  a  pea  to  a 
walnut,  or  larger,  in  shape  either  rounded,  flattened,  or  semi-globular ; 
in  consistency  they  are  either  hard  or  soft  and  doughy  ;  they  are 
freely  movable  and  painless. 

Diagnosis.    Sebaceous  cysts  may  be  confounded  with  fatty  tumors. 

Treatment.  Excision  and  careful  and  thorough  dissection  of  the 
cyst. 


DISEASES    OF  THE  SKIN.  537 

HYPERIDROSIS. 

Synonyms.     Hydrosis ;  ephidrosis  ;  idrosis. 

Definition.  A  disorder  of  the  sweat  glands,  characterized  by  an 
increased  secretion  of  sweat.  The  sweating  may  be  either  general  or 
partial,  but  unilateral  sweating,  or  hyperidrosis,  is  the  condition  here 
considered. 

Causes.  Often  undetermined  ;  occasionally  inherited  ;  diseases 
of  the  brain  and  disorders  of  the  sympathetic  nervous  system. 

Pathology.  A  functional  derangement  of  the  sudoriparous 
glands,  over  which  the  vasomotor  system  has  control.  The  char- 
acter of  the  secretion,  chemically,  may  not  differ  from  the  normal. 

Symptoms.  Hyperidrosis  may  be  acute  or  chronic,  the  amount 
slight  or  large,  being  constant  or  paroxysmal,  the  extent  general  or 
local,  and  it  may  or  may  not  be  symmetrical. 

Brornidrosis  is  the  designation  when  the  secretion  has  an  offensive 
odor. 

Chrotnidrosis  is  the  designation  when  the  fluid  poured  forth  is  vari- 
ously colored. 

Uridrosis  is  the  designation  when  the  excretion  from  the  sweat- 
glands  contains  the  elements  of  the  urine,  and  particularly  urea. 

Phosphoridrosis  is  tha^esignation  when  the  perspiration  appears 
luminous  in  the  dark. 

Local  hyperidrosis  occurs  most  commonly  upon  the  palms,  soles, 
axillae,  and  genitalia. 

Hyperidrosis  of  the  palms  may  be  so  profuse  that  the  fluid  accumu- 
lates and  keeps  the  parts  constantly  macerated,  the  wearing  of  gloves 
being  impossible,  for  as  soon  as  the  parts  are  wiped  dry  they  are  again 
bathed  in  the  secretion.  Jamieson  states  that  hyperidrosis  of  the 
hands  is  very  common  in  those  who  are  daily  excessive  spirit  drinkers. 

Hyperidrosis  of  the  soles  is  a  disagreeable  and  often  distressing 
condition,  as  the  socks  and  shoes  become  saturated,  and  thus  keep 
the  soles  constantly  bathed,  allowing  the  macerated  epidermis  to  peel 
off,  leaving  a  more  tender  skin  exposed,  causing  pain  and  distress 
when  walking.  The  maceration  of  the  epidermis,  the  secretion  about 
the  toes,  together  with  tbe  moisture  of  the  socks  and  the  soles  of  the 
shoes,  promote  the  rapid  development  of  the  bacteria  fatidtwi ;  all 
these  together  produce  a  most  disagreeable,  disgusting,  and  persistent 
odor,  which  is  termed  brotnidrosis  pedum. 


538  PRACTICE    OF    MF.DICINR. 

Hyperidrosis  of  the  genitalia  attacks  males  more  particularly,  giving 
rise  to  a  disagreeable,  penetrating  odor. 

The  sweating  may  be  limited  to  one  side — ufiilatftal  hyperidrosis. 

Prognosis.  The  majority  of  cases  are  extremely  intractable. 
Recovery,  however,  is  the  rule. 

Treatment,  The  general  condition  of  the  patient  must  receive 
proper  attention.  Atropines  sttlphas,  gr.  -j^g-^'fy  (0.00054-0.001  Gm.) 
twice  daily,  is  often  serviceable.  Ergota  in  pill  or  solution  is  useful. 
Agaricina,  gr.  J  (0.01 1  Gm.),  has  been  recommended. 

Local  treatment  \'i  the  most  valuable,  however. 

The  parts  should  be  cleansed  and  immediately  dried,  and  then 
dusted  with  some  one  of  the  numerous  dusting  powders.  The  follow- 
ing is  a  valuable  powder : 

R.     Acidi  salicylic], gr.  xx  1.3  Gm. 

Zinci  cleat., Jj  30.    Gm.  M. 

Perhaps  the  very  best  local  application  is  tinctura  belladonna, 
either  diluted  or  full  strength.  Aristol  diS  a  dusting  powder  is  very 
satisfactory. 

In  hyperidrosis  of  the  palms  and  soles,  the  following  are  valuable, 
first  washing  the  parts  with  a  weak  solution  of  acidtim  carbolicum  : 

R.     Acidi  salicylic!, _:^ss  2.  Gm. 

Cretis  praep. , 3J  30.  Gm. 

Aluminis  exsic, 3J  30.    Gm. 

M.  et  powder  finely. 

SiG. — Apply  to  parts  with  puff-ball. 

Or— 

R.      Acid,  salicylici, 3  parts 

Pulv.  aniyli, 10  parts 

Pulv.  soapstone, 87  parts.  M. 

SiG. — Sift  into  shoes  and  stockings. 

Or— 

R .     Sulphur,  lotum. , gr.  xxx  2.  Gm. 

Pulv.  arrowroot, 3  iv  15.  Gm. 

Acid,  salicylici, g""-  ^'j  0-45  Gm.           M. 

SiG. — Dust  over  feet  and  between  toes. 

Or— 

R.     Potassii  permanganat gi"- ij  0.13  Gm. 

Aquae  destil., f^j  30.       Cc.  M. 


DISEASES   OF  THE   SKIN.  539 

A  saturated  solution  of  acidum  boracicum,  alone  or  in  powder,  with 
equal  parts  of  acetatiiiidum,  applied  frequently  to  the  hands  and 
feet,  often  proves  curative. 

For  obstinate  cases,  involving  the  palms  or  soles,  the  following  plan 
of  treatment,  as  suggested  by  Hebra,  will  be  found  of  the  greatest 
service.     It  is  imperative  that  the  various  steps  be  closely  followed  : 

"  The  parts  are  to  be  cleansed  with  water  and  soap,  and  the  follow- 
ing ointment  applied  on  pieces  of  cloth  cut  to  the  size  of  the  region. 
Lint  smeared  with  the  ointment  is  also  to  be  placed  between  the  toes 
or  fingers,  so  that  every  portion  of  the  skin  may  be  covered  with  a 
layer  of  the  ointment. 

R.      Emplast.  diachyli, ^iv  I20.  Gm. 

Olei  olivas, f  5  iv  120.  Cc. 

The  plaster  to  be  melted  and  the  oil  added  and  stirred  until  a  homogeneous 
mass  results. 

SiG. — To  be  used  on  cloths. 

"  The  cloths  are  to  be  changed  every  twelve  hours,  when  the  parts 
are  not  to  be  washed,  but  rubbed  with  dry  lint  and  starch  dusting 
powder,  after  which  new  dressings  are  again  to  be  applied  in  the 
same  manner.  This  proceeding  is  to  be  continued  from  one  to  two 
weeks.  When  the  disease  is  upon  the  soles,  the  patient  may  walk 
about  in  loose  shoes."  After  a  week  or  ten  days  the  ointment  may 
be  discontinued,  but  the  dusting  powder  is  to  be  used  for  a  consider- 
able period.  If  relapses  occur,  the  original  treatment  should  again 
be  instituted. 

Painting  the  soles  and  under  and  between  the  toes  with  a  ten 
per  centum  solution  o( formalin,  morning,  noon,  and  night,  has  given 
good  results  in  a  number  of  instances.  A  few  drops  of  the  solution 
may  be  put  in  the  boot  or  shoe. 

SUDAMINA. 

Synonyms.     Sudamen  ;  miliaria  crystallina  (Hebra). 

Definition.  A  non-inflammatory  affection  of  the  sweat-glands ; 
characterized  by  the  rapid  development  of  millet-seed-sized,  translu- 
cent, whitish  vesicles  in  great  numbers  upon  any  portion  of  the  body. 

Causes.  A  high  bodily  temperature,  causing  unusual  activhy  of 
the  sudoriparous  glands. 

Pathology.     The  glands  being  excited  beyond  their  capacity  for 


5l(^  PRACTICE    OP    MEDICINE. 

normal  excretion,  the  excessive  fluid,  instead  of  escaping  upon  the 
surface,  from  some  cause  collects  between  the  layers  of  the  epidermis, 
in  the  form  of  minute,  translucent  pin-point-sized  vesicles. 

Symptoms.  An  ephemeral  rash.  Each  minute  vesicle  is  dis- 
tinct, but  they  exist  in  great  numbers,  very  closely  resembling  drops 
of  free  sweat.  They  develop  rapidly,  never  coalesce,  become  puri- 
form,  or  rupture.  Fresh  crops  form  from  time  to  time.  Their  dura- 
tion is  transitory  ;  the  fluid  is  absorbed,  the  covering  of  each  dries, 
forming  a  thin,  delicate  membrane,  which  disappears  as  a  slight 
desquamation. 

Treatment.  The  treatment  is  that  of  the  disease  with  which  they 
occur. 

ANIDROSIS. 

Definition.  A  functional  disorder  of  the  sweat-glands;  charac- 
terized by  a  diminished  or  insufficient  secretion  of  sweat. 

Causes.  The  result  of  a  congenital  deficiency  of  the  sweat  gland- 
ular apparatus.  Local  anidrosis  may  result  from  injury  to  a  nerve, 
during  the  course  of  chronic  diseases  of  the  skin,  as  ichthyosis, 
eczema,  psoriasis,  lepra,  and  elephantiasis  arabum.  In  rare  cases  an 
individual  ceases  to  sweat  entirely  at  times  ;  in  such  cases  the  general 
health  is  impaired,  and  during  the  hot  season  much  suffering  may 
result. 

Treatment.  Means  to  promote  the  activity  of  the  skin  and  glands 
is  the  indication,  such  as  the  ingestion  of  large  quantities  of  water, 
hot  baths  and  steam  baths,  friction,  and  the  use  of  sudorifics,  the  most 
valuable  of  which  is  pilocarpus. 


HYPERiEMIAS  OF  THE  SKIN. 

ERYTHEMA  SIMPLEX. 

Definition.  An  acute  affection  of  the  skin,  in  which  occurs  an 
abnormal  quantity  of  blood  in  the  dermal  vessels  ;  characterized  by 
discoloration,  which  disappears  upon  pressure  and  with  more  or  less 
local  increase  of  temperature. 

Varieties.     Idiopathic  erythema;  symptomatic  erythema. 

Causes.  Idiopathic  erythema  ;  heat,  cold,  pressure,  friction,  or 
the  contact  of  irritants,  such  as  mustard,  arnica,  and  dyestuffs. 


DISEASES    OF   THE   SKIN.  541 

Sympto7natic  erythema  occurs  most  frequently  in  childhood,  from 
diseases  of  the  stomach  and  intestines  ;  during  the  course  of  the 
various  exanthemata. 

Symptoms.  A  more  or  less  rapidly  developed  redness  of  the 
ikin,  varying  in  color  from  pink  or  light  red  to  dark  red,  which  dis- 
appears upon  pressure,  to  rapidly  return  again.  The  extent  and  form 
of  the  congestion  varies  according  to  the  cause,  at  times  being  as 
%rnall  as  a  coin  and  isolated,  and  again  diffused  over  a  large  area. 
The  temperature  of  the  congested  part  is  slightly  above  the  normal. 
Slight  itching  and  burning  are,  usually,  associated  with  the  discolora- 
tion. 

Diagnosis.  Erythema  resembles  acute  dermatitis  in  color,  but 
the  subjective  symptoms  of  the  latter  are  so  decided  that  an  error 
should  not  occur. 

Treatment.  Controlled  by  the  cause,  which  should  be  removed, 
and  the  local  application  of  some  one  of  the  various  dusting  powders. 


ERYTHEMA  INTERTRIGO. 

Definition.  An  acute  congestion  of  the  skin,  characterized  by 
redness,  heat,  increased  perspiration,  and  an  abraded  surface,  with 
maceration  of  the  epidermis. 

Causes.  In  the  fleshy,  from  contact  or  friction  of  opposing  sur- 
faces exposed  to  warmth — chafing.  In  children  and  infants,  contact 
of  moist  clothing;  also  disorders  of  digestion. 

Symptoms.  Parts  where  the  natural  folds  of  the  skin  come  in 
contact  with  one  another,  as  the  nates,  perineum,  groins,  axillae,  and 
beneath  the  mammae,  in  the  fleshy  and  in  infants,  become  red,  hot, 
painful,  and  have  an  increased  flow  of  perspiration,  which  in  turn 
softens  the  epidermis,  giving  rise  to  an  acrid,  mucoid  fluid.  If  not 
checked  by  the  removal  of  the  cause  and  the  application  of  the  dust- 
ing powders,  inflammation — dermatitis — results. 

Treatment.  The  congested  parts  should  be  thoroughly  washed 
with  water  and  Castile  soap,  or  with  bran-water,  and  carefully  dried 
with  a  soft  towel.  The  opposing  folds  of  the  skin  are  to  be  kept  sep- 
arated with  lint  or  soft  linen,  the  parts  first  covered  with  creia  p  ce- 
parata,  zinci  oxidum,  bismuthi  subnitras,  amylutn,  lycopodiiim,  or 
buckwheat-flour. 


542  rRACTICE    OF    MEDICINE. 

INFLAMMATIONS  OK  THE  SKIN. 

ECZEMA. 

Synonyms.     Tetter  ;  salt  rheum  ;  scall. 

Definition.  A  non-contagious  inflammation  of  the  skin,  charac- 
terized by  any  or  all  of  the  results  of  inflammation,  at  once  or  in  suc- 
cession, such  as  erythema,  papules,  vesicles  or  pustules,  accompanied 
by  more  or  less  infiltration  and  itching,  terminating  in  a  serous  dis- 
charge, with  the  formation  of  crusts,  or  in  desquamation. 

Forms.     Acute ;  chronic. 

Varieties.  Eczema  erythematosum  ;  eczema  papulosum  ;  eczema 
vesiculosum  ;  eczema  pusiulosum  ;  eczema  rubrum  ;  eczema  squamo- 
sum ;  eczema  fissum  ;  eczema  verrucosutn  ;  eczema  sclcrosum. 

Causes.  Eczema  attacks  persons  in  all  spheres — the  rich,  the 
poor,  the  infant  or  the  aged,  and  males  or  females.  Many  families, 
especially  those  having  the  "  catarrhal  predisposition  or  peculiarity 
of  constitution,"  seem  more  liable  ;  indeed,  it  appears  probable  that 
a  predisposition  to  eczema  may  be  transmitted  from  parent  to  child. 
Among  the  causes  suggested  are  :  dentition,  improper  food,  gastro- 
intestinal disorders,  and  imperfect  elimination  of  products  of  waste ; 
intestinal  parasites,  deficient  urinary  secretion,  the  rheumatic  and 
gouty  diatheses,  vaccination,  prolonged  contact  of  hot  fomentations, 
heat  and  cold,  and  contact  with  the  poison  vine  (rhus  toxicodendron) 
and  poison  tree  (rhus  venenata). 

Pathology.  Eczema  is  a  catarrhal  inflammation  of  the  skin — 
a  dermatitis,  with  superficial  serous  exudation.  There  is  first  hyper- 
cemia,  or  congestion  of  the  vessels  of  the  skin — eczema  erythemato- 
sum, when  uniformly  distributed,  eczema  papulosum,  when  the  con- 
gestion is  limited  to  distinct  points.  The  hyperaemia  is  soon  followed 
by  a  serous  exudation.  If  the  superficial  exudation  be  profuse  enough 
to  form  small  drops,  and  if  the  epidermis  possess  sufficient  resisting 
power  not  to  give  way  immediately  before  it,  vesicles  form,  producing 
the  variety  known  as  eczema  vesiculosum  ;  if  the  vesicles  contain  a 
large  admixture  of  young  cells,  so  that  the  serum  be  turbid,  yellow, 
and  purulent,  the  vesicles  become  pustules,  termed  eczema  pustulo- 
sum ;  if  the  serous  exudation  be  not  sufficient  to  either  elevate  or 
break  through  the  epidermis,  instead  of  either  vesicles  or  pustules 
forming,  there  occur  dry  scales,  rising  from  the  reddened   skin — 


DISEASES    OF   THE   SKIN,  543 

eczema  squamosum.  When  the  exudation  is  sufficient  to  detach  the 
epidermis,  thus  exposing  the  red  and  moist  corium,  it  is  termed  eczema 
rubrum. 

In  chronic  eczema  the  skin  is  subacutely  inflamed  ;  is  very  much 
thickened,  hardened,  and  infiltrated  with  cells  which  extend  through- 
out the  entire  corium,  even  into  the  subcutaneous  connective  tissue. 
TRe  papillae  are  enlarged  and  at  times  may  be  distinguished  with  the 
naked  eye.  Pigmentation  may  take  place  in  the  deep  layers  of  the 
rete  and  in  the  corium,  especially  about  the  vessels. 

Symptoms.  Eczema  is  the  most  common  of  all  cutaneous  affec- 
tions, with  symptoms  varying  in  accordance  with  the  particular 
variety  of  the  affection  and  the  location,  although  the  general  char- 
acteristics of  a  catarrhal  inflammation  are  present  in  all ;  these  are 
redness,  either  limited  or  diffused  ;  heat,  of  the  part  affected  ;  swell- 
ing, the  result  of  the  serous  exudation,  giving  rise  either  to  a  dis- 
charge (weeping),  with  subsequent  crusting,  or  to  the  deposition  of 
plastic  material.  The  most  constant,  annoying,  and  troublesome 
symptom  is  the  itching,  or,  at  times,  burning,  which  varies  from  that 
which  is  simply  annoying  to  that  which  is  almost  unendurable. 

Eczema  runs  its  course  either  as  an  acute  affection,  lasting  a  few 
weeks,  not  to  return,  or  to  return  acutely  at  wide  intervals,  or,  as  is 
much  more  frequently  the  case,  it  assumes  a  chronic  state,  continuing 
with  more  or  less  variations  for  months,  years,  or  even  a  life-time.  It 
may  appear  upon  any  portion  of  the  body  or  involve  the  whole  in- 
tegument {eczema  universale^.  The  varieties  are  named  in  the  order 
the  lesions  assume  at  their  commencement. 

Eczema  Erythematosiim.  An  erythema  or  redness  of  the 
surface,  with  a  yellow  tinge.  The  size  of  the  macule  may  be  very 
small  or  quite  extensive,  with  irregular  outlines.  There  may  be  slight 
swelling  of  the  patch,  but  no  discharge  occurs  unless  it  be  where  two 
surfaces  come  into  contact  {eczema  intertrigo),  as  about  the  genitalia. 
Cases  without  discharge  are  covered  after  a  few  days  with  a  thin  film 
of  dry,  enfoliating  epidermis  or  scale  {eczema  squatnosum).  When  a 
discharge  (weeping)  or  moisture  occurs,  it  is  followed  with  more  or 
less  crusting. 

Intense  itching  is  a  constant  symptom. 

Eczema  Papillosum,  or  Lichen  Simplex.  This  variety  of 
eczema  appears  in  the  form  of  small,  rounded  papules,  the  size  of  a 
pin-head,  oi  bright-rtd  or,  at  times,  dark-red  color;  they  may  be  either 


544  PRACTICE    OK    MEDICINE. 

discrete  or  confluent.  In  some  cases  all,  while  in  others  a  greater  or 
less  number,  of  the  papules  pass  into  vesicles  and  run  much  the  same 
course  as  vesicular  eczema.  The  itching  is  of  the  most  intense  char- 
acter, leading  to  severe  scratching,  by  which  the  summits  of  the 
papules  are  torn,  causing  them  to  bleed,  the  blood  forming  dark-red 
crusts. 

Eczema  Vesiculosum.  Begins  with  buttling, pain,  redness,  and 
swelling,  followed  by  an  immense  number  of  minute  vesicles,  either 
discrete  or  confluent,  rapidly  distending  with  a  clear  or  yellowish 
fluid  and  attended  with  intense  itching.  Soon  the  vesicles  rupture, 
the  fluid  rapidly  diffusing  over  the  surface  and  drying  \r\Xo yellowish, 
honey-like  crusts.  New  crops  of  vesicles  soon  follow,  or  if  subsequent 
vesications  do  not  occur,  the  fluid  rapidly  diffuses  over  the  excoriated 
surface,  which  also,  in  turn,  dries  into  large,  yellowish  crusts.  After 
a  variable  time  the  various  symptoms  gradually  subside. 

Itching  is  the  most  prominent  subjective  symptom,  is  intense,  and 
gives  rise  to  an  irresistible  desire  to  scratch. 

All  portions  of  the  body  are  liable  to  this  variety  of  eczema,  the 
most  frequent  location,  however,  being  the  face,  and  when  occurring 
in  children  is  commonly  known  as  crusia  laciea. 

Eczema  Pustulosum,  or  Eczema  Impetiginosum.  This 
variety  usually  begins  as  vesicular  eczema,  the  fluid  rapidly  changing 
to  pus.  After  a  short  period,  during  which  the  pustules  have  increased 
in  size,  they  burst  and  the  escaped  fluid  forms  thick,  greenish-yellow 
crusts,  which,  in  turn,  rapidly  dry  and  fall  off,  or  crumble  away. 

The  location  of  this  variety  is  most  usually  upon  the  scalp  and  face. 
It  is  stubborn  to  treatment.     Itching  is  a  prominent  symptom. 

Eczema  Rubrum,  or  Eczema  Madidans.  This  is  a  variety 
only  from  a  clinical  standpoint.  It  may  result  from  any  of  the  fore- 
going varieties.  The  surface  of  the  skin  is  inflamed  and  infiltrated, 
red,  moist,  and  weeping,  the  profuse  serum  rapidly  drying  into  thick, 
yellowish,  greenish,  or  brownish  crusts,  the  color  depending  upon  the 
character  of  the  fluid,  which  may  be  serum,  pus,  or  blood  from  the 
exposed  and  lacerated  corium.  The  crusts  adhere  closely  and  firmly 
to  the  part,  and  unless  removed  by  mechanical  means  may  remain 
indefinitely,  the  disease  pursuing  its  course  beneath.  Eczema  rubrum, 
or  viadidans,  "  then,  presents  two  appearances — as  it  occurs  with  its 
crust,  and  as  it  exists  without  this  covering.  In  the  one  case  the 
skin  itself  is  altogether  obscured  by  a  dirty,  yellowish,  or  brownish 


DISEASES   OF  THE  SKIN.  545 

crust ;  in  the  other  the  skin  presents  a  bright  or  violaceous  red,  punc- 
tate, wounded  surface,  deprived  in  great  part  of  its  epidermis,  and 
exuding  a  scanty  or  profuse,  clear  or  opaque,  syrupy,  yellowish  fluid. 
Sometimes  this  is  streaked  with  blood."  The  itching  and  burning 
are  severe.  It  may  develop  upon  any  portion  of  the  body,  but  is 
most  commonly  seen  upon  the  legs,  particularly  in  elderly  people. 
Its  course  is  chronic  and  increasing  in  severity. 

Eczema  Squaraosum.  This  is  also  a  clinical  variety.  It  results 
from  the  erythematous,  vesicular,  pustular,  or  papular  varieties  of  the 
affection,  but  more  particularly  the  first  named.  A  typical  case  pre- 
sents itself  in  the  form  of  variously  sized  and  shaped  reddish  patches, 
which  are  dry,  or  more  or  less  scaly,  the  skin  being  more  or  less  infil- 
trated or  thickened.     Its  course  is  usually  chronic. 

Eczema  Fissum,  or  Rim.osum.  Another  clinical  variety. 
During  the  progress  of  the  erythematous,  vesicular,  or  pustular  varie- 
ties of  eczema,  cracks  or  fissures  result  when  the  lesion  occurs  upon 
regions  subject  to  constant  motion,  such  as  between  the  fingers,  toes, 
nates,  and  the  various  joints.  At  times  the  fissures  are  extensive  and 
deep,  and  of  a  bright-red  color,  showing  the  true  skin,  and  intensely 
painful  upon  motion.  Chapped  hands  are  typical  instances  of  fissured 
eczema. 

Eczem.a  Sclerosum.  This  variety  of  eczema,  occurring  most 
commonly  on  the  palms,  soles,  and  finger-tips,  is  characterized  by 
hypertrophy  of  the  papillae,  showing  itself  as  hard,  thickened,  infil- 
trated, localized  patches,  which  are  most  apt  to  crack  (eczema  fissum). 

Eczema  Verrucosum,  or  Papillomatosum,  differs  from  the 
foregoing'in  that  the  thickened,  infiltrated  patch  has  a  warty,  verru- 
cous appearance.     Its  course  is  chronic. 

Eczema  Acutum  et  Chronicum.  The  line  which  divides 
these  two  conditions  is  drawn  by  means  of  the  clinical  and  patho- 
logical features.  The  course  of  eczema,  in  the  majority  of  instances, 
is  chronic.  It  may  be  said  that  so  long  as  the  general  inflammatory 
symptoms  are  high  and  the  secondary  changes  slight,  the  affection  is 
acute,  and  that  when  the  process  has  settled  itself  into  a  definite  line 
of  action,  continually  repeating  itself  and  accompanied  by  secondary 
changes,  it  is  chronic. 

Diagnosis.  The  many  varieties  in  which  eczema  manifests  itself 
renders  the  diagnosis  a  matter  of  importance.  The  following  charac- 
teristic features  of  eczema  are  of  value  in  arriving  at  a  diagno€is: 

35 


54f)  PRACTICE    OK    MF.DICINE. 

inflammation,  swelling,  and  (xdema,  thickening  from  cell  infiltration, 
redness,  the  discharge  of  moisture,  followed  by  crusting,  on  removal 
of  which  a  moist  surface  is  presented,  and  itching  and  burning. 

Erysipelas  may  be  confounded  with  erythematous  or  vesicular 
eczema.  The  points  of  difference  are  the  fever  and  other  general 
disturbances.  The  deep-seated  inflammation  of  the  skin,  rapidly 
spreading,  with  heat,  swelling,  and  oedema  without  moisture,  giving 
the  surface  a  deep-red,  shining,  and  tense  appearance,  are  character- 
istics of  erysipelas  and  very  different  from  eczema. 

Herpes  and  vesicular  eczema  bear  some  resemblance  to  each  other ; 
herpes  zoster  is  distinguished  by  the  neuralgic  pains  which  are  asso- 
ciated with  it  and  are  never  associated  with  eczema.  The  other  varie- 
ties of  herpes  occurring  about  the  face  and  genitalia  run  their  course 
in  a  few  days,  while  eczema  is  of  much  longer  duration  and  has  a 
discharge  followed  by  crusting. 

Seborrhea  of  the  scalp  and  squamous  eczema  of  the  same  region 
closely  resemble  each  other.  In  eczema,  however,  the  skin  is  more 
or  less  red,  inflamed,  and  thickened,  and  the  scales  larger,  less  abun- 
dant and  less  greasy  and  drier  than  seborrhoea.  In  eczema  the 
scales  are  usually  seated  upon  a  circumscribed  patch,  while  in  sebor- 
rhoea, as  a  rule,  they  cover  the  scalp  uniformly.  Itching  occurs  with 
both  disorders.  The  history  of  the  two  affections  should  be  of  material 
aid  in  rendering  the  diagnosis  clear ;  still,  however,  in  many  cases 
the  diagnosis  is  difficult.     Both  are  frequent  affections. 

Psoriasis  should  never  be  confounded  with  a  typical  case  of  eczema, 
but  chronic  eczema,  with  infiltrated,  inflammatory,  scaly  patches,  fre- 
quently looks  very  much  like  psoriasis. 

Treatment.  There  is  no  specific.  The  indications  are  for  the 
removal  of  the  cause,  where  it  can  be  ascertained,  and  attention  to  the 
general  health.  The  diet  should  be  of  the  most  nutritious,  but  easily 
digestible,  character.  Fresh  air  and  moderate  exercise  are  also  essen- 
tial elements  in  the  treatment,  together  with  attention  to  the  secre- 
tions, particularly  of  the  kidneys.  If  the  bowels  be  sluggish,  much 
benefit  follows  the  use  of  such  laxative  mineral-spring  waters  as  the 
Hathorn,  or  Hunyadi  Janos,  or  a  morning  dose  of  magnesii  sulphas. 
For  children,  syrupus  rhei,  to  which  maybe  added  magnesia;  ox, 
what  is  perhaps  more  efficient,  a  small  dose  of  hydrargyri  chloridum 
mite.  If  the  urinary  secretion  be  small  and  the  urine  heavy,  use 
should  be  made  of  full  doses  oi potassii  acetas,  and  large  draughts  of 


DISEASES   OF   THE   SKIN.  547 

water.  If  either  a  rheumatic  or  gouty  condition  exist,  lithimn  salts, 
to  which  may  be  added  vinum  colchici  semmis.  If  a  scrofulous  ten- 
dency exist,  use  oieiim  morrhuce  and  syrupus  ferriiodidi.  If  anaemia, 
ferrum,  qiimiria,  strychnina,  and  the  mifieral  acids,  or  syrupus  hypo- 
photphitum  compositus,  are  indicated.  If  the  disease  shows  a  ten- 
dency to  linger  or  relapse,  arsenicum  is  a  valuable  agent,  but  is  to  be 
avoided  in  the  acute  condition.  In  the  pustular  variety  calcii  sul- 
phidum  is  often  useful  in  doses  from  gr.  ^^  to  %  (0.003-0.016  Gm.). 
Dr.  Morrow  strongly  recommends  the  Viola  tricolor  (wild  pansy), 
particularly  for  cases  of  eczema  of  the  scalp,  or  criista  lactea. 

Locally.  The  most  important  treatment  for  all  the  varieties  of 
eczema  is  with  local  remedies,  suiting  the  appropriate  ones  for 
each  particular  case,  as  no  one  combination  is  applicable  for  all 
varieties.  It  may  be  stated  as  a  principle,  that  nothing  irritant  is 
ever  to  be  applied  to  the  surface  in  acute  eczema,  and  that  in  the 
chronic  form  nothing  can  hardly  be  too  stimulating.  The  too  frequent 
washing  or  general  baths  are  to  be  avoided,  as  they  have  a  tendency 
to  macerate  the  already  softened  epidermis.  For  cleansing  purposes, 
in  the  majority  of  instances,  ordinary  Castile  soap  is  sufficient. 

Crw.y^.j  ^«(^.yffl/^.y  are  nearly  always  present  in  eczema,  and  are  to 
be  removed  before  medicaments  can  be  successfully  applied.  Their 
removal  is  to  be  secured  by  saturation  with  oily  preparations,  a  starch 
or  other  mild  poultice,  or  a  saturated  solution  of  acidu7n  boricum  or 
diluted  boroglyceridum.  After  their  removal  the  parts  are  to  be 
cleansed  with  Castile  soap  and  water. 

For  acute  erythematous  or  vesicular  eczerna,  use  but  little,  or,  what 
is  better,  no  soap  or  water ;  instead,  covering  the  parts  with  a  dusting 
powder,  one  of  the  most  useful  being  acidum  boricum,  or — 

R .     Pulv.  camphorse, 3 j  4.  Gm. 

Zincioleat., 3^  ^-  ^™- 

Pulv.  amyli, §j  30.  Gm.  M. 

SiG. — Dusting  powder. 

For  acute  vesicular  eczema,  Dr.  J.  C.  White  recommends  bathing 
the  affected  part  with  lotio  nigra  (hydrargyri  chlor.  mite,  gr.  viij 
[0.5  Gm.],  liquor  calcis,  f  §  j  [30  Cc.]),  full  strength,  or  diluted  with 
equal  parts  of  lime-water,  applied  by  means  of  a  sponge  or  a  piece  of 
cloth  for  ten  or  fifteen  minutes  at  a  time,  and  at  intervals  of  a  few 
hours  or  longer,  the  sediment  being  allowed  to  remain  on  the  skin  ; 


548  PRACTICE    OF    MEDICINE. 

after  which  unguentum  zinci  oxiditm  is  to  be  gently  rubbed  over  the 
part.  As  a  rule,  the  itching  and  burning  are  relieved  at  once,  and 
the  affection  often  arrested.  Good  results  follow  the  application  of  a 
saturated  solution  oi  acidum  borictim. 

There  are  cases  which  do  better  from  the  application  of  ointments, 
of  which  the  following  is  valuable  : 

K.     Zinci  oleat., ^iv  15.  Gm. 

Olei  olivjE, f3iv  15.  Cc. 

M.  et  ft.  unguentum. 

Or,  bismuth  oleatc,  made  according  to  the  following  formula  of  Ur. 
McCall  Anderson  : 

R.     Bismutlii  oxidi, ,:^j  4.       Gm. 

Acidi  oleici, .    .    .  5J  30.       Gm. 

Cerre  alb^e 3  iij  12.       Gm. 

Vaselini, gix  36.       Gm. 

01.  rosce, TTLij  o.  i2Cc.  M. 

If  the  discharge  be  excessive,  the  following  formula  of  Professor 
Bartholow  is  valuable : 

R.     Pliimbi  acetat., ^ss  16.  Gm, 

Pulv.  camphorce, gr-  xv  I.  Gm. 

01.  amygdal., f  _^  ij  60.  Cc. 

Cerat.  flav. 2J  3°-  Gm.  M. 

The  late  Dr.  Frank  Maury  was  partial  to  the  following  formula  in 
vesicular  eczema : 

U.      Hydrargyri  chlor.  mitis gr.  xx  1. 3  Gm. 

Ung.  zinci  oxid.  benz., 5J  30.    Gm. 

M.  et  ft.  unguentum. 

Y or  eczema  papulosum  \.h&  following  lotions  are  particularly  valu' 
able : 

R.     Acidi  carbolici, ,^j-'j  4.-8.    Gm. 

Glycerini, f.^'v  16.  Cc. 

Alcoholis, f.^'^-vj       16. -24.  Cc. 

Aquae  destil. , ad   Oj      ad  480.  Cc.  M. 

— DUHRING. 

Or— 

R.     Thymol, ,    o    .    .    .    gr.  XT  1.  Gm. 

Alcoholis, o    .    .    .  f  5j  30.  Cc. 

Aquae  destil., f3J  30.  Cc.  M. 


DISEASES   OF   THE  SKIN.  549 

After  the  disappearance  of  the  acute  symptoms  more  stimulating 
applications  are  indicated,  among  which  are  acidum  carbo/icum, 
thymol,  pix  Uqiiida,  or  oleum  cadinum.  It  is  to  be  remembered,  how- 
ever, tlj^t  the  more  chronic  the  affection  and  the  less  the  inflamma- 
tory symptoms,  the  more  successful  is  iar  in  the  treatment  of  eczema. 
1  have  seen  excellent  results  from  resinol  ointment  in  nearly  all  varie- 
ties of  eczema. 

Dr.  Duhring  considers  the  following  one  of  the  most  elegant  of  the 
tarry  ointments ; 

R.     Olei  cadini, f^iss  6.    Cc. 

Cerati  simplicis,      5J  30.     Gm. 

01.  amygdal.   amar., gtt.  x  0.6  Cc.  M. 

Ft.  ungt. 

Or— 

R.     Picis  liquidse, f^j  4.  Cc. 

Glycerini, f^j  4.  Co. 

Alcoholis, .    .    .    .  f^vj  24.  Cc. 

01.  amygdal.  amar., gtt.  xv  I.  Cc.  M. 

SiG. — To  be  rubbed  firmly  into  the  skin. 

The  following  is  Dr.  Bulkley's  valuable  "  liquor  picis  alkalinus  "  : 

R.     Picis  liquidse, f^ij  8.  Cc. 

Potassas  causticEe, ^j  4.  Gm. 

Aquse  destillatse, It^v  20.  Cc. 

The  potassa  to  be  dissolved  in  water  and  gradually  added  to  the  tar  with 
rubbing  in  a  mortar. 

SiG. — To  be  used  diluted. 

A  very  elegant  preparation  of  tar  is  the  French  mixture  known  as 
"  Goudron  de  Guyot." 

For  eczema  rubrum,  one  of  the  most  intractable  varieties  of  the 
disease,  especially  the  chronic  eczema  of  the  legs,  the  following  mode 
of  treatment,  first  suggested  by  Hebra,  is  the  treatment^ar  excellence. 
The  accompanying  instructions  are  to  be  adhered  to.  "  A  lump  of 
the  sapo  viridis  (made  originally  of  herring-fat  and  potassa,  and  con- 
taining three  per  cent,  of  caustic  potassa),  the  size  of  a  small  nut,  is 
smeared  upon  a  piece  of  wet  flannel  and  applied  to  the  affected  part, 
and  firmly  rubbed  until  the  soap  has  disappeared,  when  the  flannel 
is  to  be  dipped  into  warm  water  and  again  applied  to  the  part  and 
rubbed  until  an  abundant  lather  forms,  more  water  being  added  from 
time  to  time  until  the  suds  are  most  abundant,  when  the  surface  is 


550  PRACTICK    OK    MEDICINE. 

thoroughly  washed  and  freed  from  all  the  soap  and  carefully  dried 
after  which  the  following  (Ilebra's  diachylon)  ointment,  having  been 
spread  before  the  application  of  the  soap,  is  to  be  applied.  It  is  pre- 
pared as  follows  : 

"  Fifteen  ounces  of  the  best  olive  oil  are  added  to  two  pounds  of 
water,  and  heated  to  boiling  in  the  water-bath.  Three  ounces  and 
six  drachms  of  an  equally  good  article  of  litharge  (plumbi  oxidum) 
are  dusted  over  the  fluid  in  ebullition,  which  is  constantly  stirred 
throughout,  in  order  to  prevent  the  formation  of  fatty  acids.  During 
the  cooking,  water  is  occasionally  added  as  required.  The  stirring  is 
to  be  continued  until  the  ointment  is  quite  cold. 

"  The  ointment  is  spread  upon  strips  of  soft  muslin  and  the  affected 
part  enveloped,  care  being  exercised  that  neither  folds  nor  wrinkles 
occur,  the  whole  being  covered  by  a  firm  roller  and  the  patient  being 
able  to  go  about  as  usual.  The  entire  operation  is  to  be  repeated 
tsvice  daily." 

A  modification  of  the  above  ointment,  technically  known  as  "  un- 
i^Hcnium  diachyliaibi  of  Nebra,"  has  been  successful  in  my  hands  in 
a  number  of  cases.     The  formula  is — 

li .     Emplast.  plumhi, 

Vaselini, ^3,    ^j  aa  30.  Gm. 

01.  lavandulre, q.  s.  q.  s.  M. 

Dissolve  with  heat  and  stir  till  cold. 
SiG. — Apply  on  strips. 

Prof.  Da  Costa  has  used  with  success,  in  eczema  rubra,  liquor 
arsenici et  hydrargyriiodidi,  n\,ij-v  (0.12-0.3  Cc),  after  meals,  and — 

IJ.     Ung-  plumbi  subacet., t^  iv  16.     Gm. 

Acid,  carbolici  cryst., gr.  iij  0.2  Gm. 

Ung.  pelrolei, 3  iv  16.     Gm.  M. 

SiG. — Apply  freely  on  muslin  strips. 

An  excellent  formula  for  eczema  of  the  vulva  is — 

R.     lodoformi, 15 ss  2.  Gm. 

Bal.  Peruviani,    ........  f_:^j  4.  Cc. 

Ung.  petrolei, 5J  30.  Gm.                M. 

SiG. — Apply  on  soft  cloths. 


DISEASES   OF  THE   SKIN.  551 


TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF 
ECZEMA. 

Eczema  capitis  is  either  erythematous,  vesicular,  or  pustular  in 
character.  If  the  first  named,  it  at  once  tends  to  become  chronic, 
settling  into  the  variety  known  as  eczema  squamosujii,  often  involving 
the  entire  scalp  and  accompanied  with  intense  itchitig.  The  pustular 
variety  is  the  more  common  form,  occurring  upon  the  scalp  of  chil- 
dren and  young  adults,  existing  as  a  few  patches,  or,  what  is  more 
frequent,  involving  the  entire  scalp.  The  pustules  soon  rupture,  the 
liquid  drying  into  greenish-yellow  crusts,  often  covering  the  whole 
scalp  with  a  cap  of  crust.  The  hair  becomes  matted  and  caked,  the 
sebaceous  secretions  collect,  and  if  the  part  is  not  cleansed,  becomes 
offensive.  In  severe  cases  of  pustular  eczema  of  the  scalp  enlarge- 
ment of  the  lymphatic  glands  of  the  back  of  the  neck  and  of  those 
behind  the  ear  occur ;  but  they  never  suppurate.  Pediculi  are  fre- 
quently associated  with  eczema  capitis  in  children,  either  as  a  primary 
cause  or  a  result  of  the  matted  condition  of  the  hair  constituting  a 
favorable  habitat  for  them. 

Eczema  capitis  may  be  confounded  with  psoriasis,  seborrhoea, 
syphilis,  tinea  favosa,  and  tinea  tonsurans. 

Treatment.  If  the  pustular  variety,  removal  of  the  crusts  is  the 
first  indication.  This  is  accomplished  by  saturating  the  scalp  either 
with  oleum  olives  or  oleum  amygdalce  dulcis,  and  then  washing  with 
warm  water  and  soap,  or  the  use  of  a  starch  poultice  or  a  twenty-five 
per  centum  solution  of  boroglyceridum  ;  after  their  removal  the  ap- 
plication of  the  following  ointment,  recommended  by  Professor  Da 
Costa : 

U.      Hydrargyri  chlor.  mitis,     .    .    .    .    gr.  xx  1. 3  Gm. 

Acid,  carbol.   cryst. , gf-  iij  0.2  Gm. 

Ung.  petrolei, ^j  30.     Gm.              M. 

SiG. — Thoroughly  applied. 

The  late  Prof.  Ellerslie  Wallace  was  fond  of  using  the  following : 

K; .      Sodii  carbonatis, gr.  xxx  2.  Gm. 

Ung.  petrolei, ^j  30.  Gm.  M. 

SiG. — Apply  thoroughly  after  removal  of  the  crusts. 

I  have  usually  been  successful  with  cleanliness,  proper  dietary,  the 
internal  use  oi liquor  arsenici et  hydrargyri iodidi,VC\^ss-]  (0.03-0.06  Cc), 


552  PRACTICE    OF    MEDICINE. 

well  diluted,  after  meals,  and  the  local  use  of  aiidum  boricum,  or 
unguenium  zinci  oxiduin,  to  which  has  been  added  a  few  drops  of 
acid  urn  carbolicum. 

In  cases  associated  •f!\\\\  pcdiculi  1  have  succeeded  with  the  follow- 
ing, after  the  removal  of  the  crusts  : 

R.      Hydrargyri  ammoniat. ,      .    .    .    .  pr.  x-xx      0.65-I.3  Gni. 

Adeps  ben/.oat. 5J  30.  Giu.  M. 

SiG. — Thoroughly  applied. 

For  the  squamous  variety  of  the  scalp,  the  following  formula,  rec- 
ommended by  Dr.  Duhring,  is  excellent: 

R.     Picis  liquidse f^j  4.  Cc. 

Glycerin! f^j  4.  Cc. 

Alcoholis, fS^j  24.  Cc. 

01.  amygdalce  amar.,  .        ....    gtt.  xv  i.  Cc.  M. 

SiG. — Diluted  or  full  strength,  rubbed  thoroughly  into  the  scalp. 

Eczema  faciei.  In  this  location  the  affection  may  be  either  acute 
or  chronic.  In  adults  the  erythematous  variety  is  frequently  encoun- 
tered in  patches  about  the  forehead  and  cheeks.  Eczema  of  the  face 
is  more  common  in  children,  however,  the  varieties  being  the  vesicu- 
lar and  pustular.  It  is  seen  on  the  forehead,  nose,  and  upper  lip,  and 
is  associated  with  severe  itching. 

Treatment.     The  same  as  eczema  capitis,  or  the  following : 

R.     Zinci  oleat., ,^i  4.  Cm. 

Ung.  petrolei 3J  30.  Gm.  M. 

Eczema  labiorum.  Eczema  attacks  the  lips,  either  alone  or  in  con- 
nection with  other  parts  of  the  face.  One  or  both  lips  may  be  affected. 
The  symptoms  are,  swelling,  redness,  heat,  infiltration,  slight  scali- 
ness,  and  fissures.  The  affection  may  be  in  the  skin  around  the 
border  of  the  mouth,  or  the  vermilion  and  mucous  membrane  of  the 
lips.  The  mouth  may  be  contracted  and  the  lips  partly  glued  to- 
gether by  the  exudation  and  crusts. 

Eczema  labiorum  may  be  confounded  with  herpes  labialis  and 
syphilis. 

Treatment.  Very  difficult  and  discomforting  to  the  patient. 
Among  the  remedies  at  times  successful  are  :  Argenti  nitras,  polassa 
nitras,  acidiim  carbolicum,  pix  liquida,  and  collodium  flexile.  I  have 
succeeded  in  several  cases  with  a  powder  composed  of  equal  parts  of 
acidum  boricum,  acetanilidum,  and  bismuthum. 


DISEASES   OF  THE   SKIN.  553 

Eczema  palpebrarutn.  A  frequent  occurrence  in  scrofulous  chil- 
dren, showing  itself  along  the  edges  of  the  eyelids.  Pustules  involve 
the  hair-follicles,  followed  by  the  usual  crusting.  The  symptoms  are 
swelling,  redness,  and  itching,  and  unless  the  parts  are  frequently 
cleansed,  the  lids  glue  together.  Conjunctivitis  frequently  compli- 
cates the  affection. 

Treat7nent.  In  mild  cases  success  follows  the  use  of  zinci  oleatujn 
or  glyceritum  acidi  tannici.  In  severe  cases  the  plan  recommended 
by  McCall  Anderson  should  be  pursued.  It  consists  in  the  extraction 
of  the  eyelashes  and  touching  the  edges  of  the  lids  with  a  solution  of 
poiassa  in  water,  ten  grains  to  the  ounce.  The  edges  should  be  care- 
fully dried  and  the  lid  everted,  a  very  small  quantity  on  a  delicate 
brush  being  applied,  immediately  neutralizing  the  alkali  with  acidum 
aceticum  or  vinegar. 

Eczema  barbce.  Eczema  of  the  beard  is  characterized  by  the  forma- 
tion of  extensive  pustules,  showing  a  preference  for  about  the  hairs, 
drying  as  yellowish  or  greenish  crusts,  matting  the  hairs  together  and 
adhering  to  the  parts.  The  affection  may  be  confined  to  the  hairy 
portions  of  the  face,  or  extend  to  other  regions  of  the  face,  be  localized 
or  general,  acute  or  chronic. 

Eczema  barbae  in  general  features  somewhat  resembles  both  tinea 
sycosis  and  sycosis  non-parasitica,  but  sycosis  is  an  inflammation  of 
the  hair-follicles  only  and  is  rarely  associated  with  crusting,  while 
crusting  is  abundant  in  eczema. 

Treatment,  Must  be  energetic  and  decided.  The  crusts  are  to  be 
removed  by  poultices  or  warm  water  and  soap.  The  part  to  be 
cautiously  shaved  ;  although  quite  painful  the  first  time,  it  is  hardly 
so  afterward,  and  it  is  to  be  repeated  every  two  or  three  days.  After 
shaving,  if  the  attack  be  acute,  the  same  plan  of  medication  as  rec- 
ommended by  Hebra  for  eczema  rubrum  is  to  be  practised,  the  ap- 
plication to  be  continuous  both  day  and  night,  or  only  at  night.  If 
the  attack  be  chronic,  the  following  ointment  should  be  applied  after 
cleansing  and  shaving  the  beard  : 

U .     Hydrargyri  ammoniat., gr.  xv-xxx  I.— 2.  Gm. 

Sulphur,  prjecipitati, ,^ss-j  2.-4.  Gm. 

Ung.  petrolei, 2J  30.  Gm.                M. 

SiG. — To  be  thoroughly  applied. 

In  this  varietv  of  eczema  I  have  seen  marked  benefit  from  the  use 


554  PRACTICE    OF    MEDICINE. 

o{  liquor  arst-nici  ft  hydrargyri  iodidi,  n\,ij-v  (0.13-0.3  Cc),  three  or 
four  times  daily. 

Eczema  auriutn.  Eczema  of  the  ears  may  be  either  erythematous, 
vesicular,  or  pustular.  If  the  former,  thickening  results,  with  desqua- 
mation of  fl.ikes  or  large  scales;  if  either  of  the  latter,  crusts  form, 
which  may  envelop  the  whole  ear,  the  symptoms  being  swelling,  red- 
ness, and  severe  burning  and  itching,  and  if  the  process  extend  into 
the  meatus,  occlusion  may  result,  causing  temporary  deafness.  The 
most  characteristic  symptom  of  erythematous  eczema  of  the  external 
auditory  canal,  besides  the  appearance  of  small  flakes,  is  intense  and 
persistent  itching. 

Treatment.  For  acute  vesicular  or  pustular  eczema,  removal  of  the 
crusts  and  the  use  of  hydrargyri  chloridum.  mite  as  an  ointment  of 
the  strength  of  thirty  grains  (two  grams)  to  the  ounce  (thirty  grams). 
If  chronic,  the  use  oi pix  liquida,  as  already  suggested.  For  chronic 
erythematous  eczema  of  the  external  auditory  canal,  the  following 
formula  has  generally  controlled  this  stubborn  condition  : 

B  .      Hydrargyri   flav.  oxid., g*"- j-''j  0.65-0.2  Gm. 

Morphinje  sulph., gr.  j  0.65  Gm. 

Vaselini, ^ij  8.  Gm.  M. 

SiG. — Apply  to  the  canal. 

Eczema genitaliion.  This  is  a  most  distressing  condition.  In  the 
male  the  scrotum  and  penis  are  involved  alone  or  together,  the  former 
alone  being  the  more  common,  and  is  complicated  with  eczema  of 
the  inner  side  of  the  thigh  or  thighs.  The  symptoms  are  ;  swelling, 
often  oedema,  moisture,  crusts,  and  painful  fissures,  followed  by  ex- 
tensive thickening  and  accompanied  with  intense  itching.  In  the 
female  the  affection  attacks  the  labiae,  and,  rarely,  the  vagina  and 
mons  veneris,  and  may  extend  to  the  surrounding  parts,  especially  to 
the  perineum.  The  symptoms  of  eczema  of  the  labia  are ;  great  swell- 
ing, oedema,  redness,  with  great  heat  and  a  free  discharge,  forming 
crusts,  which  are  apt  to  glue  the  opposing  surfaces  together.  If  the 
•variety  be  the  erythematous,  in  place  of  a  discharge  with  crusts,  the 
symptoms  named  are  followed  by  slight  scales.  The  itching  is  most 
violent  and  distressing. 

Treatment.  The  parts  attacked  should  be  kept  constantly  envel- 
oped in  cloths  wet  with  a  saturated  solution  of  aciduvi  boricum  until 
the   more  pronounced   inflammatory  symptoms   subside,  when  the 


DISEASES   OF   THE   SKIN.  555 

acidum  boricum  may  be  used  as  a  dusting  powder,  completely  en- 
veloping the  parts.  Mild  solutions  of  menthol  are  valuable.  Tinc- 
tura  inyrrhce  or  hamamelis,  well  diluted,  are  excellent  applications. 
The  following  is  an  excellent  application  for  tetter  of  the  scrotum  : 

R.      Acidi  borici, q.  s.  for  sat.  sol. 

Tinct.  myrrh., f^ss  l6.     Cc. 

Tinct.  camphorae, i^i]  _  60.     Cc. 

Hydrarg   chlor.  cor., gr.  iij  0.2  Gm. 

Aquje  destil.,      .    .    .    .    q.  s.  adf^viij    q.  s.  ad  240.     Cc.  M. 

SiG. — Apply  several  times  daily. 

Ointments  oi  zmci  oleatum  or  hydrargyri  chloridntn  mite  are  some- 
times valuable.  Persistent  cases  will  often  succumb  to  the  plan  of 
treatment  suggested  by  Hebra  for  eczema  rubrum.  Resinol  ointment 
is  often  successful. 

Eczejtia  ani.  The  anus  may  be  attacked  alone  or  associated  with 
eczema  of  the  perineum  and  genitalia.  The  symptoms  are,  redness, 
swelling,  infiltration,  and  thickening,  with  or  without  fluid  exudation. 
Fissures  of  the  anus  are  usually  present,  and  add  to  .the  distress  of 
the  patient,  severe  pain  attending  each  stool.  Persistent  itching  and 
burning,  worse  after  retiring,  add  to  the  discomfort  of  the  patient. 

Pruritus  ani  may  be  mistaken  for  eczema  ani.  In  the  former  the 
itching  is  only  associated  with  such  symptoms  of  inflammation  as 
resultfrom  the  irritation  of  scratching,  while  in  the  latter  inflammatory 
symptoms  precede  the  itching. 

Treatment.  The  more  acute  symptoms  are  relieved  by  bathing  the 
parts  with  a  solution  of  acidum  boricum,  after  which  a  weak  applica- 
tion of  acidum  carbolicum,  either  as  a  lotion  or  ointment.  Resinol 
ointment  is  invariably  curative.  The  late  Prof.  S.  D.  Gross  recom- 
mended the  application  of  the  following  : 

R.     Zinci  oxidi, ^vj  24.       Gm. 

Hydrargyri  chlor.  corrosiv.,     .    .    gr.  j  0.65  Gm. 

Glycerini, f  3  ij  8.       Cc.             M. 

SiG. — Apply  thoroughly  to  affected  parts. 

Eczema  intertrigo.  Parts  of  the  body  that  naturally  come  into  con- 
tact with  each  other,  as  about  the  joints,  the  inner  surfaces  of  the 
nates,  in  the  groins,  and  beneath  the  mammse,  are  frequently  attacked 
with  erythematous  eczema,  which  is  frequently,  but  erroneously, 
termed  erythema  intertrigo,  or  chafing.     The  symptoms  are,  redness, 


55G  PRACTICE    OF   MEDICINE. 

heat,  and  a  moist,  macerated  surface,  aggravated  by  movement  of 
the  affected  parts. 

Treatment.  The  application  of  a  solution  of  acidtun  boruion,  or 
the  use  of  dusting  powders,  such  as  zinci  oleatum,  aniyluni,  or  hvdrar- 
gyri  chloridiim  mite.  It  is  essential  for  successful  treatment  that  the 
opposing  surfaces  be  separated  by  means  of  lint  or  gauze. 

Eczema  mainmarum.  The  nipples,  and  more  particularly  those  of 
primiparae,  are  at  times  the  seat  of  a  vesicular  eczema,  with  the  for- 
mation of  crusts  and  fissures,  and  unless  speedily  relieved,  develop 
eczema  rubrum.  The  pain  on  nursing  becomes  so  severe  that  the 
mother  is  compelled  to  refuse  the  child.  It  must  be  borne  in  mind 
that  eczema  mammarum  occurs  in  women  who  are  not  nursing  and 
in  single  women. 

Treatment.     Dr.  Tilbury  Fox  advises  the  following  plan  : 

"  I.  Great  cleanliness  and  care  in  washing  away  any  remnants  of 
milk  after  each  time  that  the  child  is  put  to  the  breast;  and  if  the 
nipple  be  tender  and  excoriated,  use — 

"  2.  A  little  liquor  plumbi  and  calamine  powder,  as  follows  : 

R.     Liq.  plumhi, f  ^  iss  6.  Cc. 

Pulv.  calaminD?  pnep., 3  '='S  6.  Gm. 

Glycerini,     . fzj  4.  Cc. 

Adeps, 5J  30.  Gm.  M. 

"3.  I  cover  over  the  nipple  with  a  lead  nipple-shield.  This  excludes 
the  air,  keeps  the  part  from  being  chafed,  and  I  think  the  lead  does 
good  after  the  part  has  become  less  red  and  sore.  I  often  use  a  little 
glyceritum  acidi  iannici,  painted  on  night  and  morning. 

"  The  above  application  can  always  be  removed  with  a  little  cold 
cream  and  a  little  warm-water  sponging  before  the  child  goes  to  the 
breast." 

Eczema palmarum  et  plantarum.  The  features  of  the  affection  in 
both  these  regions  are  identical.  The  diagnosis  is  often  obscured  by 
the  thickened  state  of  the  epidermis.  The  symptoms  are,  infiltra- 
tion, thickening,  callosity,  moisture  followed  by  dryness,  and  fissuring, 
the  last  named  frequently  becoming  so  deep  and  painful  that  the 
patient  is  unable  to  use  his  hands,  or,  if  on  the  soles,  to  walk. 

The  affection  is  always  chronic,  affecting  either  of  the  parts  alone, 
or  all  at  one  and  the  same  time.  Itching  is  a  constant  and  annoying 
symptom. 


DISEASES   OF  THE  SKIN.  557 

The  diagnosis  is  to  be  made  between  eczema  of  these  parts  and 
psoriasis  or  syphiHs. 

Treatment,  The  plan  of  Hebra  for  eczema  rubrum  will  usually  be 
successful  for  this  variety.     The  following  formula  is  also  valuable : 

R.     Hydrargyri  cleat.,  5-15  per  cent.,    J^iv  16.  Gm. 

Olei  cadini, f^ss  2.  Cc. 

Carat,  simplicis,       ^iv  16.  Gm.  M. 

SiG. — Rub  well  into  part  morning  and  night,  first  macerating  with  hot 
water. 

Eczema  unguium.  The  nails  are  seldom  attacked  alone,  but  in 
connection  with  eczema  manuum.  The  symptoms  are  roughness, 
want  of  polish,  unevenness,  and  a  punctate  or  honeycomb  appear- 
ance, similar  to  that  seen  in  psoriasis  of  the  nails.  The  nail  becomes 
depressed,  particularly  at  its  root,  thus  interfering  with  its  nutrition, 
resulting  in  loss  of  this  appendage. 

Treatmetit.  Internally,  arsenicum  is  a  valuable  remedy.  Locally 
the  following  : 

R.     Ung.  picis  liq., giv  16.  Gm. 

Hydrargyri  chlor.  raitis,     .    .    .    .  ,^  ss  2.  Gm. 

Vaselini, giv  16.  Gm.  M. 

SiG. — Apply  thoroughly. 

It  is  a  remarkable  clinical  fact  that  very  many  cases  of  eczema, 
whether  acute,  subacute,  or  chronic,  are  rapidly  cured  by  the  use  of 
potassii  iodidum  in  variable  doses  continued  for  a  long  period. 


URTICARIA. 

Synonyms.     Hives ;  nettle-rash.  '  . 

Definition.  An  inflammation  of  the  skin  characterized  by  the 
development  oi  wheals  of  a  whitish,  pinkish,  or  reddish  color,  accom- 
panied by  stinging,  pricking,  and  tingling  sensations,  often  associated 
with  febrile  and  gastric  symptoms. 

Causes.  Very  frequently  the  result  of  sudden  surface  hypersemia, 
or,  rather,  too  rapid  circulation  through  the  superficial  capillaries,  the 
result  of  exposure  to  heat.  Irritants  and  poison  produce  an  attack 
when  brought  in  contact  with  the  skin.  Gastric,  intestinal,  hepatic, 
nephritic,  ovarian,  uterine,  and  bladder  derangements  are  very  fre- 
quent causes.     Certain  medicaments  ;  malaria  ;   nervous  disorders ; 


558  PRACTICE    OF    MEDICINE. 

associated  with  purpura  and  rheumatism ;  pregnancy ;  lactation, 
and  the  menopause. 

Pathology.  An  acute  inflammation  of  the  papillary  layer  of  the 
skin,  characterized  by  the  rapid  development  of  a  "  wheal" — a  more 
or  less  firm  elevation — consisting  of  a  circumscribed  collection  of  a 
semifluid  material,  the  result  of  a  rapid  exudation  into  the  upper 
layers  of  the  skin.  The  production  of  the  wheal  is  the  immediate 
result  of  a  disturbance  of  the  vasomotor  system,  which  is  shown  by 
the  interference  of  the  circulation  in  the  wheal,  the  blood  being 
driven  from  its  centre  to  its  periphery,  causing  the  whitish  apex  and 
red  areola  so  characteristic  of  the  developed  "  hive." 

Symptoms.  An  attack  of  "hives  "  is  characterized  by  the  sud- 
den development  of  ivJuah  upon  the  cutaneous  surface,  which  usu- 
ally as  suddenly  disappear,  their  site  being  temporarily  marked  by  a 
spot  of  redness  or  hyperaemia. 

With  the  appearance  of  the  wheal  occur  distressing  itching,  biirn- 
insr,  iittirlinir,  crawlins',  -tirickimr,  and  stins^n^  sensations,  to  relieve 
which  the  patient  still  further  irritates,  tears,  or  otherwise  wounds  the 
surface  by  scratching,  whence  are  often  developed  deep-colored,  flat, 
lenticular  papules. 

Very  frequently  an  attack  of  "hives"  is  associated  •w'x'Ca.  fever, 
headache,  and  gastric  disorder.  The  "  wheals  "  may  appear  upon 
any  portion  of  the  body  ;  their  size  varies  from  that  of  a  pea  to  that 
of  a  walnut  or  an  t.g'g — the  "giant  wheals";  the  number  varying 
from  a  very  few  to  being  so  numerous  as  to  cover  the  whole 
surface.  The  shape,  size,  color,  and  number  of  the  wheals  that 
may  occur  have  given  rise  to  a  number  of  names  to  designate  the 
lesions.  Thus,  urticaria  annularis  occnrs  in  rings  ;  urticaria  figurata 
occurs  in  spirals  ;  urticaria  vesiculosa  has  a  vesicular  development 
on  the  summit  of  the  wheal ;  urticaria  bullosa,  a  bullous  develop- 
ment at  the  summit ;  urticaria  papulosa,  or  lichen  urticatus,  the 
wheal  and  a  small  papule  are  combined ;  urticaria  tuberosa,  or 
giant  wheals ;  urticaria  hemorrhagica,  or  purpurata  urticaria,  a 
combination  of  urticaria  and  purpura ;  urticaria  evanida,  a  rapid 
appearance  and  disappearance  of  the  lesion  ;  urticaria  perstans, 
slow  disappearance;  urticaria  conferta,  when  the  wheals  are  con- 
fluent; tirticaria  pigmentosa,  when  the  wheals  are  succeeded  by 
pigmentations  of  the  site,  the  tints  varying  from  dark  brown,  green- 
ish yellow,  to  a  chocolate  color ;  urticaria  febrilis,  when  the  wheals 


DISEASES   OF  THE  SKIN.  559 

are  associated  with  fever ;  urticaria  ab  ingestis,  when  associated  with 
indigestion. 

Treatment.  To  prevent  the  recurrence  of  the  disorder,  a  thor- 
ough investigation  of  the  cause  must  be  instituted. 

Attention  should  be  directed  to  the  general  health,  the  diet,  and 
the  secretions. 

The  following  remedies,  alone  or  variously  combined,  are  often  of 
benefit :  quinifta,  pilocarpus,  atropina,  tinctura  beiladonfice,  aimnonii 
chloridtim,  arsenictim,  and  potassii  broniidum.  Sodii  salicylas,  gr. 
iij-v  (0.2-0.3  Gm.),  every  hour  or  two,  followed  by  a  thorough  purga- 
tion, often  acts  like  a  specific.  The  following  pill  is  valuable  in  many 
cases : 

R .     Pulv.  pilocarpi, 

Ext.  guaiaci, aa   gr.  iss  aa  o.  I  Gm. 

Lithii  benzoat. , gr-  iij  0.2  Gm.  M. 

SiG. — Two  to  four  each  twenty-four  hours. 

If  there  be  atonic  dyspepsia  and  constipation,  the  following  com- 
bination is  useful : 

R.     Magnesii  sulphat., ^j  30.  Gm. 

Ferri  sulphat. , gr.  xvj  I.  Gm. 

Sodii  chloridi, ^ss  2.  Gm. 

Acidisulphurici  dil., f,:^ij  8.  Co. 

Infus.  cascarillse, f^iv  1 20.  Co.  M. 

SiG. — Tablespoonful  before  breakfast,  diluted. 

Ztf^a/ measures  are  of  the  greatest  value,  either  as  baths,  lotions,  or 
dusting  powders.  The  following  are  among  the  most  serviceable  : 
sponging  with  alcohol,  brandy,  whiskey,  vinegar  and  water,  witch- 
hazel,  salt  water,  alkaline  baths,  and  acid  baths.  Duhring  recom- 
mends the  following : 

R.     Acidi  carbolici, 3  iss  6.  Gm. 

Glycerini, f^^^ij  8.  Co. 

Alcoholis, {"^  viij  240.  Co. 

Aq.  amygdal.  amar. , f^"^'ij  240.  Co.  M. 

SiG. — Use  as  a  lotion  two  or  three  times  daily. 

Bulkley  suggests  the  following  : 

R .     Chi  oralis, 

Camphoras, ^  3J  ^^  4-  Gm. 

Misce,  and  rub  and  incorporate  with 

Pulveris  amyli, ,lj~ij  30.-60.  Gm. 

Misce,  and  keep  tightly  corked  in  a  wide-mouthed  bottle, 
SiG. — Rub  in  with  hand. 


660  PRACTICE    OF    MEDICINE. 

A  serviceable  formula  is  the  following; 

li .     Chlorofornii, fxj  4.  Cc. 

Ung.  zinci  oxid., 5  ij  60.  Gm.  M. 

SiG. — Apply  to  wheals. 


HERPES. 

Definition.  An  acute  inflammation  of  the  skin,  characterized  by 
the  development  of  one  or  more  groups  o{  vesicles,  filled  with  a  clear 
serum,  occurring  for  the  most  part  about  the  face  (Iter pes  facialis^  and 
genitalia  {herpes  f>rogenitalis). 

Causes.  Herpes  facialis  ;  during  the  course  of  febrile  and  nerv- 
ous disorders  ;  associated  with  digestive  disorders  and  colds. 

Herpes  progenitalis ;  the  origin  is  local,  from  uncleanliness  or 
friction. 

Pathology.  Hebra  defines  the  various  forms  of  herpes  as  "  a 
series  of  acute  cutaneous  diseases  of  cyclical  course,  marked  by  an 
exudation  which  collects  in  drops  under  the  epidermis  and  elevates 
it,  forming  vesicles  which  are  never  solitary,  but  always  appear  in 
groups." 

Symptoms.  The  appearance  of  the  vesicles  is  usually  preceded 
by  a  feeling  of  heat  in  the  region,  together  with  slight  tumefaction  or 
swelling.  Rarely  the  herpetic  attack  is  attended  with  malaise  and 
pyrexia. 

The  eruption  usually  appears  in  the  form  of  a  small  cluster  of  pin- 
head  to  split-pea  sized  vesicles,  containing  a  clear  fluid,  becoming 
cloudy,  afterward  puriform,  and  drying  in  small,  yellowish  or  brownish 
crusts;  they  are  few  in  number,  and  may  coalesce.  They  disappear 
without  leaving  a  scar. 

Herpes  facialis ;  occur  upon  any  portion  of  the  face,  but  most  fre- 
quently about  the  lips — herpes  labialis.  The  alae  of  the  nose,  auricles, 
and  the  mucous  membranes  of  the  mouth  and  tongue  are  frequent 
locations,  in  the  latter  appearing  as  excoriated  patches  from  rupture 
of  the  vesicles. 

Herpes  progenitalis ;  in  the  male  the  chief  site  is  the  prepuce 
{herpes prcEpiitialis').  In  the  female  they  are  comparatively  rare  ;  but 
when  occurring,  it  is  upon  the  labiae  majora  and  minora  and  the  skin 
about  the  vulva. 


DISEASES   OF  THE  SKIN.  561 

This  variety  is  preceded  by  burning,  itching,  or  neuralgic  pains, 
accompanied  by  redness,  congestion,  and  more  or  less  oedema. 

The  lesion  about  the  genitalia  is  likely  to  be  mistaken  for  one  form 
or  other  of  venereal  disease. 

Herpes  gestationis ;  a  rare  affection  of  the  skin  occurring  during 
pregnancy,  consisting  of  erythema,  papules,  vesicles,  and  bullae,  at- 
tended with  intense  burning  and  itching.  It  may  appear  at  any  time 
of  pregnancy  up  to  the  seventh  month,  and  continues  until  some 
time  after  delivery. 

Treatment.  Herpes  facialis  seldom  calls  for  treatment,  although 
in  marked  cases  oi  herpes  labialis  protection  with  liquor  guttapercha 
or  collodium  fiexile  promotes  desiccation. 

Herpes proge7iitalis ;  cleanliness  is  of  the  first  importance.  Coat- 
ing the  eruption  with  the  medicaments  mentioned  above,  or  washing 
with  a  saturated  solution  of  acidum  boricutn,  and  afterward  dusting 
with  hydrargyri  chloridum  jnite,  are  useful.  In  recurring  cases  of 
herpes  of  the  vulva,  arsenicum  is  a  specific  (Jonathan  Hutchinson). 

The  parts  may  be  rendered  less  sensitive  in  frequently  recurring 
cases  by  astringent  lotions,  as  acidum  tannicutn  or  zinci  sulphas. 
Circumcision,  when  required,  may  be  practised. 


HERPES  ZOSTER. 

Synonyms.     Zono  ;  shingles  ;  a  girdle  ;  intercostal  neuralgia. 

Definition.  An  acute,  inflammatory  disease  ;  characterized  by 
the  development  of  groups  of  firm  and  distended  vesicles  situated 
upon  inflamed  bases  corresponding  to  a  definite  nerve  trunk,  and 
accompanied  by  more  or  less  severe  neuralgic  pains. 

Causes.  The  eruption  and  consequent  neuralgic  pains  are  the 
immediate  result  of  an  inflammation  of  the  ganglia  or  of  the  nerve 
trunks  and  branches, — a  neuritis, — probably  of  the  trophic  fibers  of 
the  affected  part ;  but  the  cause  producing  this  condition  is  obscure. 
Among  the  many  that  have  been  suggested  are  :  cold,  injuries  to 
nerves,  anaemia,  malaria,  and  the  medicinal  use  of  arsenicum. 

Pathology.     An  inflammation  of  either  the  ganglia,  the  nerve 
trunk,  or  branches — probably  the  trophic  system — causing  the  devel- 
opment of  vesicles  in  the  lower  strata  of  the  rete  with  "  the  infiltra- 
tion of  serum  and  inflammatory  cells  "  of  the  papillae  and  corimn, 
36 


5f)2  PRACTICE    OF    MEDICINE. 

Symptoms.  Begins  with  neuralgic  pains,  either  of  a  burning  or 
lightning-like  character,  with  slight  febrile  phenomena,  followed  by 
the  appearance  of  papulo-vesicles  along  the  tract  of  pain  ;  these  soon 
become  vesicles  situated  on  bright-red,  highly  inflamed  bases.  The 
vesicles  are  about  the  size  of  pin-heads,  or,  perhaps,  a  little  larger; 
usually  discrete,  although  they  frequently  coalesce,  forming  irregular 
patches,  coming  in  groups  until  the  third  to  the  fifth  or  even  tenth 
day,  when  they  gradually  desiccate,  and  at  the  end  of  the  second 
week  nothing  remains  but  a  slight  scar,  which  may  disappear  or 
become  permanent. 

When  the  eruption  is  at  its  height,  it  is  perfect  in  its  anatomical 
formation,  each  vesicle  being  well  shaped  and  seated  on  a  bright-red, 
inflamed  patch  of  skin,  and  distended  with  a  translucent,  yellowish 
fluid. 

The  eruption  is  almost  invariably  confined  to  one  side  (unilateral) 
of  the  body,  although  in  rare  instances  it  is  seen  upon  both  (bilateral) 
sides.  It  is  usually  found  upon  well-known  nerve  tracts.  According 
to  the  region  affected  it  is  termed  zoster  capitis,  zoster  frontalis,  zoster 
faciei,  zoster  ophthalmicus,  zoster  a:<ricularis,  zoster  nuchcv,  zoster 
brachialis,  zoster  pectoralis,  zoster  abdominalis,  zoster femoralis. 

Diagnosis.  The  lesions  of  shingles  are  usually  so  well  marked 
that  an  error  in  diagnosis  should  not  occur.  The  neuralgic  pain 
preceding  the  eruption  and  its  development  in  distinct  groups  upon 
inflamed  bases  following  a  nerve  tract  are  so  different  from  the  simple 
herpes  of  the  face  or  genitalia,  or  from  the  lesion  of  eczema. 

Prognosis.  Favorable.  The  affection  is  self-limited,  the  dura- 
tion being  about  two  weeks.  It  is  said  that  "  zoster  of  the  orbital 
region  may  seriously  involve  the  eye  and  prove  fatal." 

Treatment.  The  affection  is  self-limited.  The  indications  are  to 
relieve  the  pain  and  protect  the  vesicles  from  irritation.  The  follow- 
ing combination  diminishes  the  pain  and  modifies  the  duration  : 

R .     Zinci  phosphidi, 

Ext.  nucis  vomicse, aa  gr.  x  aa  0.6  Gm.  M. 

Fi.  pil.  No.  XXX. 

SiG. — One  every  two  to  four  hours.     (Bulkley.) 

Prof.  Bartholow  "  has  seen  excellent  results  in  cases  of  shingles 
from  galvanization  of  the  affected  intercostal  nerves — the  positive 
pole  being  placed  over  the  point  of  emergence  of  the  nerves,  and  the 
negative  brushed  over  the  terminal  filaments  of  the  skin." 


DISEASES   OF   THE  SKIN.  563 

The  general  symptoms  are  to  be  treated  as  indicated.  Anaemia  or 
depression  are  benefited  by  full  doses  oi  ferri  et  guiniticE  citras. 

For  the  pain  no  remedy  seems  comparable  with  the  hypodermic 
use  of  morphmce  sulphas,  gr.  }4-/i  (0.008-0.022  Gm.),  with  a/ro/>in<z 
sulphas,  gr.  -^^  (0.00065  Gm.),  near  the  lesion.  Antipyrin,  gr.  xv 
(i  Gm.),  repeated  every  three  or  four  hours,  or  phenacetin,  gr.  v 
(0.3  Gm.),  every  three  or  four  hours,  relieves  the  pain  in  many  cases. 
Sodii  salicylas  gr.  x-xv  (0.6-1  Gm.)  every  few  hours  is  recommended. 

Locally,  relief  follows  coating  the  "  shingles"  with  either  coUodhivi 
flexile  or  liquor  guita  perchce,  io  which  7norphincs  sulphas  maybe 
added.  Aristol  dusted  over  the  lesions,  or  acidum  boricum,  as  a.  pow- 
der, or  combined  with  lanolin,  is  useful. 


MILIARIA. 

Synonyms.  Lichen  tropicus ;  miliaria  rubra ;  miliaria  alba ; 
prickly  heat. 

Definition.  An  acute  inflammation  of  the  sweat  glands  ;  char- 
acterized by  the  development  of  discrete,  whitish  or  reddish,  pin-point 
and  millet-seed-sized  papules,  vesicles,  or  vesiculo-papules,  productive 
of  prickling,  tingling,  and  burning  sensations  of  a  most  aggravated 
character,  associated  with  more  or  less  malaise. 

Causes.  Excessive  heat,  the  result  of  excessive  or  tightly-fitting 
clothing,  or  a  high  external  temperature.  Most  frequent  in  fleshy 
adults  who  perspire  freely,  and  in  children.  Nervous  prostration; 
severe  dyspepsia  and  general  debility  seem  to  predispose  to  "prickly 
heat." 

Varieties.     Miliaria  papulosa  ;  jniliaria  vesiculosa. 

Pathology.  The  pathology  of  the  two  varieties  is  the  same — both 
inflammatory  affections  of  the  sweat  glands  ;  in  the  one  papules,  in  the 
other  vesicles,  develop  about  the  orifices  of  the  excretory  ducts. 

In  either  variety  occurs  hypersemia  of  the  vascular  plexus  of  the 
sweat  glands,  followed  by  slight  exudation  about  the  ducts,  giving 
rise  to  the  minute  papules  or  vesicles,  which  remain  until  the  cause 
has  been  modified  or  removed,  when  they  are  rapidly  absorbed. 

Symptoms.  Miliaria  papulosa,  known  as  lichen  tropicus  and 
"  prickly  heat,"  is  of  sudden  onset,  with  the  occurrence  of  numerous 
minute,  acuminated  bright-red  papules,  about  the  size  of  a  pin-head 


■"JIU  PRACTICE   OF    MEDICINE. 

or  millet-seed,  and  but  slightly  raised  above  the  level  of  the  skin. 
The  papules  are  preceded  by  and  accompanied  with  sTOt-a/in^  {hy pari- 
drosis) and  dislressin^  tingling,  pricking,  and  burning  senaations. 
If  the  attack  be  severe,  lU'sico-papules  and  vesicles  are  freely  inter- 
spersed among  the  numerous  papules.  Rarely  the  secretion  of  sweat 
is  notably  diminished. 

Miliaria  vesiculosa;  in  this  variety,  instead  of  papules,  immense 
numbers  of  vesicles  develop,  of  the  size  of  pin-points  and  pin-heads, 
of  a  whitish  {miliaria  alba)  or  yellowish-white  color.  The  surf.ice 
from  which  they  arise  is  of  a  bright-red  color,  owing  to  each  vesicle 
being  surrounded  by  an  areola  {miliaria  rubra).  The  vesicles  are 
preceded  and  accompanied  with  sweating  (hyperidrosis)  and  most 
distressing  iingli?ig, pricking,  and  burning  sensations. 

Either  variety  may  attack  all  parts  of  the  body,  but  the  abdomen, 
chest,  back,  neck,  and  arms  are  the  regions  usually  invaded. 

Duration.  This  varies  with  the  cause.  It  may  appear,  fully  de- 
velop, and  disappear  in  a  few  hours.  In  those  predisposed  it  may 
continue  more  or  less  marked  throughout  the  entire  summer. 

Diagnosis.  If  the  cause,  nature,  and  seat  of  the  affection  are 
taken  into  consideration,  no  error  should  occur. 

Eczema  papulosum  has  a  resemblance  to  "  prickly  heat,"  but  the 
course  of  eczema  is  slow,  and  the  papules  are  larger,  more  elevated, 
and  firmer  than  those  of  miliaria  papulosa. 

Eczema  vesiculosum  and  miliaria  vesiculosa  are  to  be  differentiated 
by  the  marked  differences  in  the  progress  of  each, — the  former  slow, 
the  latter  rapid;  the  vesicles  of  the  former  rupturing  spontaneously, 
those  of  the  latter  only  when  severely  irritated. 

Sudamen  is  not  an  inflammatory  affection,  while  miliaria  is. 

Prognosis.  The  affection  is  often  most  rebellious  in  fleshy  per- 
sons and  children,  and  if  neglected,  it  passes  into  eczema  or  an 
erythematous  intertrigo. 

Treatment.  The  patient  should  be  kept  as  cool  as  possible,  and 
avoid  undue  perspiration.  The  fears  entertained  by  the  laity,  of 
danger  from  retrocession  of  the  eruption,  are  groundless  ;  the  sooner 
it  disappears,  the  better  for  the  comfort  of  the  patient. 

The  food  should  be  light  and  unstimulating,  dispensing  with  meats 
and  condiments  for  a  few  days;  wine,  spirits,  and  beer  are  to  be 
avoided. 

The  ingestion  of  water,  lemonade,  Apollinaris  water,  Vichy  water, 


DISEASES   OF   THE   SKIN.  565 

together  with  refrigerant  diuretics,  as  potassii  citras  vel  aceias,  a  cool 
apartment,  and  absolute  rest  will  ordinarily  insure  speedy  relief. 
Saline  cathartics  are  invaluable. 

Locally  :  sponging  with  alkaline  lotions,  liquor  plumbi  subacetatis 
diluttts,  extractumgrindelicsfluidum  well  diluted,  or  a  solution  of  haiit- 
amelis,  or  cupri  sulphas  in  solution  (gr.  x — 0.6  Gm.,  aqtice  f^j — 30 
Cc),  or  acidi  carbolici  (gr.  xx — 1.3  Gm.),  glyceriti  amyli  (§iij — 90 
Gm.),  or  a  dusting-powder  consisting  of  lycopodium,  zinci  oxidiim, 
and  amylum,  singly  or  combined. 


PEMPHIGUS. 

Synonym.     Water  blisters. 

Definition.  An  inflammatory  disease  of  the  skin,  either  acute  or 
chronic,  characterized  by  the  development  of  a  succession  of  rounded, 
irregular-shaped  blebs  or  bullae,  varying  in  size  from  a  pea  to  an  egg. 

Varieties.     Pemphigus  vulgaris  ;  pemphigus  foliaceus. 

Causes.  Obscure.  It  is  usually  associated  with  a  depressed  state 
of  the  general  system  ;  disorders  of  menstruation  ;  during  preg- 
nancy. 

Pathology.  Hebra  thus  describes  the  appearance  of  the  blebs  : 
"Sometimes  a  circumscribed,  light-red  spot  appears,  perhaps  of  the 
size  of  a  bean  or  a  large  coin  ;  this  is  paler  in  the  centre,  and  may 
even  present  a  tinge  of  white,  indicating  the  point  at  which  the  bleb  is 
to  form,  and  from  which  it  will  spread  outward  over  the  surrounding 
skin,  and,  in  fact,  is  at  first  a  wheal,  passing  afterward  into  a  bleb. 
In  other  cases  the  bleb  is  not  preceded  either  by  a  red  spot  or  by  a 
wheal,  but  begins  originally  as  a  small  collection  of  clear  fluid  beneath 
the  cuticle.  Thus,  hyperaemia  of  the  skin  may  exist  before  exudation 
is  poured  out,  or  the  latter  may  be  formed  before  any  congestion  of 
the  papillary  layer  is  discoverable." 

The  contents  of  the  blebs  or  bullae  are  yellowish  or  colorless  serum, 
of  a  neutral  or  alkaline  reaction ;  the  older  the  fluid,  the  more  alkaline 
it  becomes.  In  the  late  stages  of  a  bleb  the  fluid  becomes  puriform. 
In  rare  instances  blood  is  contained  in  the  bleb  (^pemphigus  hemor- 
rhagicus). 

Symptoms.  Pemphigus  vulgaris  ;  the  onset  is  slow  (^pemphigus 
chronicus),  without  constitutional  symptoms,  or  acute  (^pemphigus 


566  PRACTICE    OF    MEDICINE. 

acutus),  preceded  by  febrile  reaction.  The  lesions  are  the  successive 
development  of  blebs,  usually  from  half  a  dozen  to  a  dozen,  varying 
in  size  from  a  pea  to  an  egg,  of  a  round  or  oval  shape,  their  walls 
distended  with  a  colorless  fluid,  the  color  becoming  yellowish  or  puri- 
form  as  they  grow  older.  They  develop  abruptly  from  the  sound 
skin,  with  a  definite  line  of  demarcation,  unattended  with  symptoms 
of  inflammation.  A  characteristic  phenomenon  of  the  lesion  is  its 
successive  appearance ;  a  crop  no  sooner  disappears  than  another 
forms,  throughout  the  course  of  the  aff^ection,  each  crop  running  its 
course  in  from  three  to  six  or  ten  days.  With  the  appearance  of  the 
blebs  occur  itching  2ir\6.  burning,  usually  of  a  mild  character,  although 
occasionally  in  a  distressing  degree  {pcviphigtis pruriginosus). 

Pemphigus  jnalignus  is  characterized  by  the  great  size  and  number 
of  the  blebs,  which  coalesce,  rupture,  and  are  succeeded  by  excoriated 
surfaces,  which  occasionally  take  on  ulcerative  action,  the  patient's 
health  being  seriously  impaired. 

Pemphigus  foliaceus  differs  from  pemphigus  vulgaris  in  that  the 
blebs,  instead  of  being  distended  or  tense,  are  flaccid  and  only  par- 
tially filled  with  fluid,  as  they  rupture  before  arriving  at  their  state  of 
full  development.  This  variety  also  appears  and  disappears  in  crops. 
After  rupture  the  fluid  immediately  dries  into  thin,  whitish  flakes, 
which  are  detached  in  quantity,  leaving  a  red,  excoriated  surface — ;, 
the  rete  and  corium.  If  the  affection  has  continued  for  some  time, 
the  skin  presents  the  appearance  of  a  superficial  scald.  The  course 
of  this  variety  is  essentially  chronic. 

All  portions  of  the  body  are  liable  to  the  lesion,  as  also  the  mucous 
membrane  of  the  mouth  and  vagina.  It  is  most  common,  however, 
upon  the  limbs. 

Diagnosis.  In  a  typical  case  no  difificulty  should  be  experienced 
in  making  a  diagnosis.  The  mere  presence  of  blebs,  however,  does 
not  necessarily  constitute  pemphigus,  for  it  must  be  remembered  that 
they  are  at  times  developed  in  other  diseases,  as  well  as  by  artificial 
means;  the  appearance  of  blebs  in  crops  is  a  strong  diagnostic  point. 

Prognosis.  The  course  of  the  affection  is  most  uncertain,  and 
relapses  are  frequent.  In  arriving  at  an  opinion  the  occurrence  of 
fatal  cases  must  not  be  forgotten. 

Treatment.  Attention  to  the  general  health  is  of  the  greatest 
moment.  A  careful  study  of  the  cause  should  be  made,  and,  if  deter- 
mined, means  for  its  removal  are  of  the  first  importance. 


DISEASES    OF   THE   SKIN.  567 

Two  remedies,  arsefiicuni  and  quinina,  are  of  great  value,  the  secret 
of  success  being  the  persistent  use  of  the  former  ;  or  if  the  latter  be 
used,  the  dose  should  be  large. 

Local  measures  are  also  of  importance.  The  blebs  should  be 
punctured  and  evacuated  as  soon  as  formed.  The  use  of  dusting- 
powders  of  acidtim  boricum,  zinci  oxidicm,  amyhmt,  or  violet-powder, 
or  lotions  ol  liquor phi77ibi subacetatis  dilnium,  are  valuable. 

Hebra  recommends  the  continuous  bath. 


IMPETIGO. 

Definition.  An  acute  inflammatory  disease,  characterized  by  the 
development  of  one  or  more  discrete,  rounded  and  elevated,  firm 
pustules,  about  the  size  of  a  pea,  unattended  with  itching. 

Causes.  Occurs  for  the  most  part  between  the  ages  of  three  and 
ten  years,  in  the  well-nourished  and  healthy.  It  is  not  associated  with 
eczema.     It  is  not  contagious. 

Pathology.  The  lesion  is  a  well-  formed,  typical  pustule,  develop- 
ing abruptly  from  the  surface,  containing  a  whitish-yellow  fluid,  pus- 
corpuscles,  blood-corpuscles,  epithelial  cells,  and  cellular  detritus. 
The  abscess  or  pustule  is  about  the  size  of  a  pea,  circumscribed,  and 
superficial. 

Symptoms.  Begins  by  the  development  of  from  one  or  two  to  a 
dozen  or  more  distinct  pustules,  about  the  size  of  a  split  pea,  of  a 
rounded  shape,  raised  above  the  surface,  with  thick  walls,  of  a  yellow- 
ish or  whitish  color,  surrounded  by  a  distinct  areola,  which  soon 
fades,  are  without  a  central  depression  or  umbilication,  and  unat- 
tended by  either  itching  or  burning. 

The  affection  runs  an  acute  course,  usually  lasting  a  couple  of 
weeks.  The  pustules,  after  attaining  their  full  size,  remain  stationary 
for  a  few  days,  when  they  disappear  by  absorption  and  desiccation, 
the  crusts  dropping  off,  displaying  a  reddish  base,  which  soon  disap- 
pears without  pigmentation  or  scar. 

The  pustules  occur  on  all  portions  of  the  body,  the  most  frequent 
locations  being  the  face,  hands,  fingers,  feet,  and  toes. 

Diagnosis.  Impetigo  is  unassociated  with  general  symptoms, 
and  its  particular  lesion — the  pustule — is  discrete, — points  of  impor- 
tance in  the  diagnosis. 


508  PRACTICE    OF    MEDICINE. 

Eczeniii  pustulosum  is  also  a  pustular  afTection,  but  the  large  num- 
ber, their  disposition  to  coalesce,  their  location  upon  an  inflammatory 
base,  their  rupture  and  subsequent  crusting  and  itching,  are  diag- 
nostic points. 

The  diagnostic  points  from  ecthyma  will  be  pointed  out  when 
describing  that  affection. 

Prognosis.     Favorable. 

Treatment.  The  pustules  should  be  opened  as  soon  as  they 
mature,  the  contents  removed  by  washing  with  tepid  bichloride  water 
and  the  floor  covered  with  hydrargyri  cJiloridum  mite  or  zinci  olealiim. 

Coating  the  pustules  with  coUodium  flexile  or  liquor gutta  percha, 
if  they  are  located  where  irritation  be  liable,  is  valuable. 


ECTHYMA. 

Definition.  An  affection  of  the  skin,  characterized  by  the  forma- 
tion of  one  or  more  large,  isolated,  flat  pustules,  situated  upon  an  in- 
flamed base. 

Causes.  It  is  most  common  among  those  who  live  in  squalor  and 
poverty,  and  in  delicate  and  poorly-nourished  children.  Improper 
and  insufficient  diet,  want  of  ventilation,  excessive  work,  and  un- 
tleanliness  are  all  prominent  causes. 

Pathology.  The  lesion  is  a  typical  pustular  process,  severe  but 
superficial,  and  not  extending  beyond  the  papillary  layer  of  the 
corium.  The  pustule  is  situated  upon  a  firm  and  highly  inflamed 
base;  the  number  varies  from  one  to  a  dozen  or  more. 

Symptoms.  The  disease  is  characterized  by  the  development  of 
one  or  more,  round  or  oval,  yeijlat,  pustules,  about  the  size  of  a  pea- 
bean,  attended  with  moderate  heat,  burtiing,  and  pain,  and,  if  the 
number  be  large,  slight  febrile  reaction.  The  pustules  are  first 
yellowish  in  color,  surrounded  by  a  firm  and  sensitive  bright-red 
areola,  the  pustule  afterward  becoming  reddish  from  the  admixture 
of  blood,  soon  drying  into  flat  crusts  of  a  brownish  color.  The  dura- 
tion of  each  pustule  is  between  two  and  three  weeks,  new  ones  form- 
ing until  the  cause  is  removed. 

The  most  prominent  sites  are  the  thighs,  legs,  shoulders,  and  back. 

Diagnosis.  Ecthyma  and  eczema  pustulosum  have  points  of 
resemblance,  but  a  study  of  the  clinical  history  of  the  latter  should 
prevent  error. 


DISEASES   OF  THE   SKIN.  569 

Impetigo  differs  from  ecthyma  in  the  size  of  the  pustule  and  crust. 

Ecthyma  differs  from  a  boil  in  not  having  a  central  core. 

Prognosis.  With  care  and  the  removal  of  the  cause,  recovery  is 
always  prompt. 

Treatment.  The  general  treatment  of  the  patient  is  of  the  first 
importance.  Nutritious  and  wholesome  food,  cleanliness,  bathing, 
fresh  air,  and  regulated  exercise  should  be  advised,  together  with  such 
tonics  2^^  ferritin,  arsenictim,  quinina,  strychtiina,  and  mineral  acids. 

Locally :  Remove  the  crusts  by  first  soaking  with  oil  or  fat,  or  water 
dressings,  and  apply — 

R .     Ungt.  zinci  oxid.  benz.,     ....  ,^ss  15.     Gm. 

Vaselini, ^  ss  15.     Gm. 

Hydrargyri  ammoniati, 9J  1.3  Gm.         M. 

Ft.  ungt.     (Duhring.) 

Pustules  showing  a  sluggish  disposition  to  heal  should  be  stimulated 
by  touching  with  either  argenti  nitras  or  acidum  carbolicum. 


FURUNCULUS. 

Synonyms.     Furunculosis  ;  furuncle  ;  boil. 

Definition.  An  acute  affection  of  the  skin,  characterized  by  the 
occurrence  of  one  or  more  circumscribed  cutaneous  or  subcutaneous 
abscesses  (boils),  which  usually  terminate  by  necrosis  of  the  central 
tissue,  its  subsequent  expulsion  in  the  form  of  pus  or  a  core,  and  a 
resulting  cicatrix. 

Causes.  The  result  of  a  depraved  condition  of  the  system,  induced 
by  general  debility,  excessive  fatigue,  nervous  depression,  improper 
food  and  exercise,  ansemia,  diabetes,  uraemia,  or  the  result  of  local 
friction,  pressure,  or  contusions. 

Pathology.  The  process  resulting  in  a  "boil"  has  its  origin  in 
either  a  sebaceous  gland,  a  sweat  gland,  or  a  piliary  follicle,  and  never 
begins  in  the  meshes  of  the  corium.  "  It  begins  as  a  small,  roundish 
spot  which  increases  in  size  until  certain  dimensions  are  attained, 
when  it  undergoes  suppurative  change,  resulting  in  the  formation  of  a 
central  point  or  core,  composed  of  the  tissue  of  the  gland  in  which 
the  furuncle  originated,  which,  together  with  the  pus,  is  cast  off.  It 
shows  no  disposition  to  become  diffuse,  being  always  a  circumscribed 
inflammation.  After  the  discharge  of  the  core  a  cavity  of  more  or 
less  depth  remains,  showing  the  tissues  around  it  to  be  hard  and  infil- 


570  PKACTICK    OF    MEDICINE. 

trated.  After  a  fcv-  days  or  a  week  it  fills  up  by  granulation,  leaving 
a  cicatrix  which  is  often  permanent.  The  central  point  or  core,  wnen 
thrown  off,  is  composed  of  a  whitish,  tough,  pultaceous  mass  of  dead 
tissue,  varying  in  size  with  the  extent  and  depth  of  the  inflammation" 
(Duhring). 

Hydro-adenitis,  as  seen  in  the  axillae,  around  the  nipples,  and 
about  the  anus  or  perineum,  differs  from  the  ordinary  "  boil  "  merely 
in  being  deeper  seated. 

Symptoras.  "  Boils  "  niay  occur  singly,  or  more  commonly  in 
crops  of  two,  three,  or  more,  another  crop  following  their  disappear- 
ance {furuncitlosis). 

The  abscess  begins  as  a  small,  rounded,  imperfectly  defined,  xso- 
\a.ted,  reddis/i  spot,  of  a  highly  injhinied  character,  painful  on  pressure, 
its  size  gradually  increasing,  its  central  point  presenting  evidences  of 
suppuration.  It  reaches  its  full  development  in  about  a  week,  when 
it  consists  of  a  slightly  raised,  rounded,  and  pointed  inflammatory 
swelling,  with  a  yellowish  point  in  the  centre — the  "  core."  Abscesses 
with  no  central  suppuration  or  core  are  called  "  blind  boils."  The 
size  of  a  developed  boil  varies  from  a  split-pea  to  a  walnut,  the  color 
deep  red,  with  a  yellow  centre,  and  is  surrounded  by  a  slight  areola. 
The  pain  of  a  boil  is  dull  and  throbbing,  painful  on  pressure,  and  is 
usually  worse  at  night.  The  constitutional  symptoms  are  mild  or 
severe,  according  to  the  number  and  size  of  the  lesions. 

Any  portion  of  the  body  may  be  attacked  ;  its  preference,  however, 
is  for  the  face,  neck,  back,  axillae,  nipples,  buttocks,  anus,  perineum, 
and  labiae. 

Diagnosis.  The  characteristics  of  furuncle  are  so  marked  that 
an  error  seems  impossible.  It  may  be,  however,  mistaken  for  car- 
buncle, the  differences  between  which  will  be  pointed  out  when  dis- 
cussing that  affection. 

Prognosis.  No  danger  results  from  occasional  boils,  but  when 
occurring  in  crops,  they  impair  the  general  health  and  are  rebellious  to 
treatment. 

Treatment,  The  treatment  of  a  single  boil  is  well  expressed  in 
the  word  "  time."  Warm  applications  are  said  to  hasten  the  stage  of 
suppuration,  and  when  reached,  an  incision  permits  the  expulsion  of 
the  "core,"  after  which  the  cure  soon  follows.  If  the  lesion  is  located 
where  friction  or  pressure  is  likely,  protection  by  either  covering  with 
adhesive  or  soap-plaster,  smoothly  spread,  is  ample. 


DISEASES    OF   THE   SKIN.  571 

When,  however,  successive  crops  of  boils  occur  {^furunculosis),  the 
treatment  should  be  both  constitutional  and  local.  The  general 
health  being  below  par,  such  tonics  as  arsetiicinn ,  quinina ,  and  feriutn 
are  of  value.  Calcii sulphiduvi ,  gr.  ■x^-\  (0.0065-0.008  Gm.),  every  two 
or  three  hours,  is  valuable  in  these  cases. 

Locally,  attempts  to  abort  the  process  may  well  claim  attention, 
among  which  are  :  crucial  incisions,  to  relieve  the  tension  of  the  cen- 
tral point,  will  often  abate  the  inflammation  and  prevent  the  gan- 
grene ;  this  little  operation  is  rendered  painless  by  the  use  of  the 
ether  spray.  Acidum  carbolicinn,  used  in  five  per  centum  solution,  of 
which  two  to  five  drops  may  be  injected  into  the  apex  of  the  boil,  is 
valuable.  Painting  the  forming  boil  with  argenti  nitras  or  tinctura 
iodi  is  also  recommended.  A  paste  made  by  adding  together  equal 
parts  oi glycerinu7n  and  extractum  belladonnce,  will  often  abort  a  boil ; 
the  same  is  also  claimed  for  unguentiim  hydrargyri  nitratis. 


CARBUNCULUS. 

Synonyms.     Carbuncle  ;  anthrax. 

Definition.  An  indurated,  more  or  less  circumscribed,  dark-red, 
painful,  deep-seated  inflammation  of  the  skin  and  subcutaneous  con- 
nective tissue,  terminating  in  a  slough  and  the  subsequent  production 
of  a  permanent  cicatrix. 

Causes.  Not  positively  determined.  A  deep-seated  bruise  is  a 
supposed  cause.  Perhaps,  as  in  furuncle,  impairment  of  the  general 
health  is  the  important  factor.  It  is  generally  noted  to  occur  in  men 
more  frequently  than  in  women.  Diabetes  mellitus.  A  "  specific  " 
cause  for  anthrax  is  not  an  improbable  discovery. 

Pathology.  Although  Billroth  regards  furuncle  and  carbuncle 
as  differing  only  in  degree,  the  explanation  of  Warren,  of  Boston, 
seems  the  more  probable,  he  being  the  first  to  call  the  attention  of 
histologists  "  to  the  existence  of  small  columns  of  adipose  tissue  lead- 
ing from  the  panniculus  adiposus  up  to  the  roots  of  the  lanugo  hairs, 
taking  an  oblique  direction  in  a  line  with  the  erectores  pilorum.  The 
inflammation  resulting  in  suppuration  of  the  subcutaneous  adipose 
tissue  must  either  form  an  abscess  or  become  diffuse.  In  phlegmo- 
nous erysipelas  the  latter  condition  is  observed  ;  but  when  the  inflam- 
mation is  in  the  dermoid  texture,  the  exudates  infiltrate  the  skin  and 


572  PRACTICE    OF    MEDICINE. 

naturally  follow  the  canals  occupied  by  the  '  columnae  adiposae.'  The 
pressure  thus  exerted  upon  the  whole  dermoid  tissue  cannot  fail  to 
strangulate  the  circulation,  and  thus  produce  gangrene  of  the  tissue, 
even  if  the  exudate  be  not  poisonous  enough  to  destroy  the  cells  by 
its  presence.  It  can,  by  this  explanation,  be  easily  understood  why 
this  disease  is  apt  to  affect  the  skin  on  the  nape  of  the  neck  and  the 
b.ick  more  than  on  other  parts  of  the  body.  At  tliis  point  the  skin 
is  dense,  its  fibrous  element  extending  deep  into  the  adipose  layer, 
which  is  surrounded  by  strong  bands;  hence,  the  pus  confined  in 
such  a  place,  seeking  the  easiest  outlet,  will  travel  along  these  minia- 
ture adipose  canals,  producing  the  peculiar  appearance  pathognomo- 
nic of  carbuncle." 

Symptoms.  Carbuncle  is  recognized  by  its  form  :  commencing 
in  the  lower  layers  of  the  cutaneous  tissue,  it  first  resembles  a  phleg- 
mon, minus  its  bright  redness.  At  first  it  is  somewhat  rounded, 
with  a  tendency  to  the  production  of  vesicles  on  its  surface,  soon, 
however,  becoming  firm,  circular,  and  flat,  and  raised  above  the 
surrounding  parts,  spreading  through  the  subcutaneous  tissue  and 
skin,  becoming  at  times  enormously  large,  and  having  a  dark-red 
or  violaceous  color.  As  the  disease  progresses  the  pressure  of  the 
carbuncles  results  in  the  softening  of  the  tissues,  the  skin  becoming 
gangrenous,  breaking  down  at  numerous  points,  forming  perforations, 
through  which  centres  of  suppuration  appear  in  different  stages  of 
advancement,  either  as  whitish,  fibrous  plugs,  or  as  cavities,  from 
which  a  yellowish,  sanious  fluid  oozes,  the  surface  of  the  anthrax 
having  a  cribriform  appearance,  perforated  like  a  sieve.  The  entire 
mass  terminates  in  a  slough,  which,  on  being  detached,  leaves  a  large, 
open,  deep  ulcer,  with  firm,  everted  edges,  granulating  slowly,  a  per- 
manent cicatrix  marking  the  site  of  the  lesion.  The  development  of 
the  carbuncle  is  attended  by  severe  pain,  of  a  deep,  throbbing,  and 
burning  character. 

The  constitutional  symptoms  vary  with  the  size,  number,  and  severity 
of  the  disease;  loss  of  appetite,  coated  tongue,  general  malaise,  and 
moderate  febrile  reaction  accompany  all  cases,  to  which  are  added 
those  of  septicaemia  in  severe  cases. 

The  duration  is  from  two  to  six  weeks.  Its  favorite  site  is  the  back 
of  the  neck,  shoulders,  back,  and  buttocks.     It  is  usually  single. 

Diag"nosis.  The  disease  is  distinguished  from  furuncle  by  its 
great  size,  itsjiat  form,  its  course,  the  multiple  points  of  suppuration, 


DISEASES   OF   THE   SKIN.  5Y3 

and  the  character  of  the  slough;  also  by  the  pain  ;  in  furuncle,  sen- 
sitive and  painful  to  the  touch,  carbuncle  not  being  particularly 
sensitive.  Furuncles  generally  occur  in  numbers  or  in  crops ;  car- 
buncle is  almost  always  single. 

Prognosis.  A  guarded  opinion  should  always  be  given,  as  death 
is  not  infrequent  from  anthrax,  especially  in  elderly  people  with 
impaired  health.  The  mortality,  however,  is  not  so  great  as  the  laity 
suppose. 

A  great  danger  is  septicaemia,  from  the  action  of  the  poison  on  the 
blood,  or  the  result  of  secondary  abscesses. 

Treatment.  Constitutional  and  local  measures  are  both  of  the 
greatest  value.  Nutritious  diet,  stimulants,  and  full  doses  of  such 
remedies  as  tinctura  ferri  ckloridi,  quinince  sulphas,  arsenicum,  and 
atnmonii  carbonas  are  beneficial.  Good  results  are  reported  from 
calcii  sulphidum,  gr.  ]/%  (0.008  Gm.),  every  two  hours. 

Locally:  the  crucial  incision,  so  generally  practised  in  former 
years,  is  seldom  performed  now,  the  frequent  occurrence  of  hemor- 
rhages being  too  debilitating. 

A  saturated  solution  of  pure  acidum  carbolicum  injected  through  the 
several  apertures  in  every  direction  into  the  sloughing  tissues  by  the 
aid  of  a  hypodermic  syringe  is  often  successful.  The  pam  is  severe, 
but  short-lived. 

Prof.  Agnew  recommends  painting  collodhnn  cum  cantharide 
around  the  anthrax  in  the  form  of  a  broad  zone,  the  effect  of  the 
blister  being  to  relieve  the  tension.  Tinctura  iodi  is  also  used  for  a 
similar  purpose.  Hebra  advocates  cloths  wrung  out  in  ice-water,  or 
ice  bags,  in  the  early  stages,  changing  to  warm  fomentations  as  soon 
as  suppuration  has  begun.  Dr.  Ashhurst  has  practised  with  success 
the  use  of  pressure  by  means  of  adhesive  plaster  applied  in  much  the 
same  manner  as  for  swollen  testicle.  Success  often  follows  the 
application  of  Mnguentum  hydrargyri  nitratis,  spread  at  least  one- 
eighth  of  an  inch  thick  and  covered  with  adhesive  plaster,  changing 
every  twenty-four  hours. 

The  resulting  ulcer,  after  expulsion  of  the  slough,  is  to  be  treated 
on  general  principles. 


574  PRACTICE    OF    MEDICINE. 

ACNE. 

Synonyms.  Acne  vulgaris;  acne  disseminata;  varus;  stone- 
pock. 

Definition.  An  inflammation,  usually  chronic,  of  the  sebaceous 
glands ;  characterized  by  the  development  of  papules,  tubercles,  or 
pustules,  or  by  a  combination  of  such  lesions,  usually  in  various  stages 
of  formation,  occurring  for  the  most  part  upon  the  face. 

Varieties.     Acne  papulosa  ;  acne  pustiilosa  ;  acne  artificialis. 

Causes.  Not  always  understood,  as  the  affection  is  frequently 
associated  with  apparently  the  most  robust  health.  A  frequent  cause 
is  puberty.  Among  the  other  causes  observed  are  gastro-intestinal 
disorders,  anaemia,  chlorosis,  uterine  disorders,  urethral  irritation, 
scrofula,  and  the  use  of  large  doses  of  the  bromides  and  the  iodides. 
Acne  may  exist  alone  or  be  associated  with  comedo  or  seborrhcea. 

Pathology.  An  inflammation  of  the  sebaceous  gland  structure 
and  surrounding  tissues.  There  first  occurs  retention  of  the  sebaceous 
secretion,  which  is  soon  followed  by  hyperaemia  and  exudation  about 
the  glands  and  in  the  gland  wall  {acne papulosa),  infiltration  of  the 
connective  tissue  {acne  iubercula),  followed  by  suppuration  {acnepus- 
ijilosa).  If  the  inflammatory  action  be  severe,  destruction  of  the  gland 
with  a  resulting  cicatrix  occurs. 

Symptoms.  Acne  papulosa  or  acne  punctata.  This  variety  is  the 
earliest  stage  of  the  inflammatory  action,  and  is  of  short  duration, 
soon  followed  by  the  development  oi  pus.  It  is  characterized  by  the 
occurrence  o^  pin-head  \.o  pea-sized,  flat,  more  or  less  pointed  papules, 
situated  about  the  sebaceous  follicles,  lightish  in  color,  with  a  minute 
central  black  point,  the  opening  of  the  sebaceous  duct.  Pustules  are 
not  infrequently  observed  scattered  among  the  papules.  The  lesion 
is  unaccompanied  with  either  local  or  constitutional  symptoms. 
While  the  forehead  is  the  most  frequent  seat  for  this  variety,  they 
sometimes  are  seen  elsewhere. 

Acne  pustulosa.  This  is  the  fully  developed  affection.  It  is  seen 
upon  the  face,  neck,  shoulders,  and  back  as  pin-head  to  pea-sized, 
rounded  or  acuminated  pustules,  seated  upon  an  infiltrated,  reddish 
base  of  superficial  or  deep  inflammatory  product  {ac7ie  indurata). 
Scattered  among  the  pustules  may  be  seen  numerous  papules.  There 
are  no  constitutional  symptoms,  nor  is  pain  present  unless  the  pustule 
be  handled. 


DISEASES   OF   THE   SKIN.  575 

Acne  artificialis  is  rather  a  clinical  variety,  the  result,  usually,  of 
large  doses  of  the  bromides  or  iodides,  the  lesion  being  identical  with 
acne  pustulosa. 

Diagnosis.  The  lesion  is  so  characteristic,  the  course  so  chronic, 
and  the  location  so  frequently  upon  the  face,  that  an  error  seems  im- 
possible. 

The  resemblance  of  the  papular  and  pustular  syphiloderms  must 
not  be  mistaken  for  acne. 

Prognosis.  Essentially  a  chronic  affection,  lasting  for  a  number 
of  years;  but  if  persistent  treatment  be  employed,  recovery  will  occur. 

Treatment.  To  successfully  combat  an  attack  of  acne,  both  con- 
stitutional and  local  measures  must  be  employed. 

Constitutional  treatment.  The  successful  treatment  of  a  case  of 
acne  depends  upon  a  knowledge  of  the  cause  and  familiarity  with  the 
constitutional  habits  of  the  patient.  Disorders  of  digestion  and  consti- 
pation should  be  corrected.  If  anaemia  be  present,y^;77^7«  and  arseni- 
cwn  are  indicated.  Scrofula  is  an  indication  for  oleiwi  moirhua  and 
ferri  iodidum.  Uterine  disorders,  if  present,  should  receive  proper 
attention.  In  young  adult  males  I  have  seen  wonderful  improvement 
follow  the  passage  of  a  fair-sized  bougie  once  or  twice  weekly. 

Calcii  sulphidum,  gr.  x^\  (0.0065-0.032  Gm.),  every  two  or  three 
hours,  is  valuable  in  many  cases,  as  is  hydrargyri  chloriduin  corro- 
sivum,  gr.  xso-bV  (0.00065-0.00 ii  Gm.),  three  times  daily.  A  remedy 
highly  spoken  of  by  Dr.  Bulkley  is  glycerinutn  in  tablespoonful  doses 
two  or  three  times  daily.  Dr.  Duhring  recommends  that  it  be  given 
in  combination  wxih  ferri  et  quinincB  citrus.  Professor  Bartholow 
has  seen  excellent  results  from  the  use  of  syrupus  hypophosphittim 
compositus  in  acne  indurata. 

Local  treatment.  In  acne  of  not  very  long  duration  I  have  seen 
excellent  results  from  the  following  plan  :  Just  before  retiring,  the  parts 
affected  are  to  be  thoroughly  washed  with  water  as  hot  as  can  possibly 
be  borne,  and  after  the  water  has  partly  dried,  the  parts  are  to  be 
thoroughly  covered  with  sulphur  sublimatum,  applied  by  means  of  a 
powder  puff  ball,  no  rubbing  or  friction  to  be  employed,  and  on 
arising  in  the  morning  the  sulphur  is  to  be  washed  off  with  hot  water 
and  the  face  lightly  mopped  dry,  or,  what  is  better,  sulphur  again 
applied,  if  the  patient  is  willing  to  permit  it,  during  the  day. 

Dr.  Hyde  recommends  that  the  contents  of  the  papules  and  pustules 
be  evacuated  by  means  of  a  needle,  rather  encouraging  slight  bleed- 


576  PRACTICE    OF    MEDICINE. 

ing,  after  which  the  parts  are  to  be  bathed  with  water  as  hot  as  can  be 
tolerated,  and,  while  the  part  is  still  wet,  it  is  thoroughly  scrubbed 
with  lotio  saponis  viridis,  then  cleansed  with  water,  carefully  dried 
and  anointed  with  a  sulphur  ointment. 

Professor  Bartholow  suggested,  in  a  case  o{ acne  ttuiiirata  seen  with 
the  author,  the  following  successful  plan.  To  dissolve  the  sebaceous 
matter — 

R.     Liquor  potassae, f^j  4.  Cc. 

Aqua:  deslil.,      f5J  30.  Cc.  M. 

SiG. — Applied  to  the  acne  spots  only. 

After  which  they  were  anointed  with — 

R.     Plumbi  nitrat. gr-  xv  I.  Gni. 

Ung.  petrolei, 5J  30.  Gm.  M. 

SiG.  —  Apply  twice  daily. 

Dr.  Duhring  recommends  the  use  of  the  following,  after  washing 
the  parts  with  hot  water  : 

R.     Sulphuris  prcccip., 3J  4.     Gm, 

Giycerini, f^ss  2.     Cc. 

Adeps  benzoat., 5J  30.     Gm. 

01.  rosie,     . 'U,  i'j  0.2  Cc.  M. 

Ft.  unguentum. 

SiG. — To  be  thoroughly  rubbed  into  the  skin  at  night. 


ACNE   ROSACEA. 

Synonyms.     Gutta  rosea  ;  rosacea. 

Definition.  A  chronic  hyperaemia  or  inflammatory  affection  of 
the  nose  and  cheeks  ;  characterized  by  redness,  hypertrophy  of  the 
skin,  and  dilatation  and  enlargement  of  the  blood-vessels  supplying 
the  part,  with  the  development  of  more  or  less  acne. 

Causes.  Not  always  determined.  It  occurs  in  young  women 
about  puberty  who  are  anaemic,  or  suffer  from  a  general  debility^ 
nervous  irritability  or  prostration,  dyspepsia,  or  menstrual  irregulari- 
ties. It  often  appears  during  the  menopause.  In  young  males  the 
affection  can  often  be  traced  to  nervous  or  general  debility  or  dys- 
pepsia. The  use  of  spirituous  liquors  or  of  large  amounts  of  condi- 
ments is  a  frequent  cause,  as  is  constant  exposure  to  the  weather.  It 
is  firequently  associated  with  seborrhcea. 


DISEASES   OF   THE   SKIN.  577 

Pathology.  There  first  occurs  blood  stasis  in  the  vessels  of  the 
part,  producing  the  undue  redness  first  noticed.  As  a  result  of  the 
stasis,  sooner  or  later  the  capillaries  are  dilated  and  hypertrophied, 
and  following  the  interrupted  circulation  inflammation  of  the  sebace- 
ous gland  (acne)  occurs,  with  the  development  of  papules  and  pus- 
tules. This  constitutes  the  typical  acne  rosacea.  The  affection  may- 
proceed  no  further,  remaining  at  this  point  for  years,  or,  rarely,  the 
pathology  of  this  stage  is  exaggerated,  the  involved  tissues  all  hyper- 
trophying,  and  the  connective  tissue  undergoing  a  true  hyperplasia, 
causing  increased  size  and  abnormal  shape  of  the  nose. 

Symptoms.  The  onset  of  the  affection  is  slow  and  insidious, 
characterized  at  first  by  more  or  less  diffused  redness  of  the  part,  the 
color  aggravated  by  water  or  cold  air.  If  the  nose  be  the  part  at- 
tacked, it  is  usually  greasy  (seborrhoeic),  and  is  apt  to  be  cool  or  even 
cold.  This  condition  may  remain  for  years,  but  sooner  or  later  the 
evidence  of  dilatation  and  hypertrophy  of  the  capillaries  is  apparent 
by  the  more  decided  and  permanent  redness,  and  upon  close  exami- 
nation the  enlarged  minute  cutaneous  blood-vessels  are  seen  as  deli- 
cate or  coarse  red  lines,  running  superficially  over  the  skin  in  an 
irregular  and  tortuous  course.  Soon  are  developed  upon  the  hyper- 
asmic  and  hypertrophied  skin  papules  (acne  papulosa)  and  pustules 
(acne  pustulosa),  their  number  never,  however,  being  very  great. 
This  cottstitutes  true  acne  rosacea.  The  disease  may  remain  in  this 
state,  or,  rarely,  the  cutaneous  tissues  are  greatly  hypertrophied,  the 
blood-vessels  enormously  dilated,  the  glands  enlarged,  and  the  con- 
nective tissue  undergoes  hyperplasia,  resulting  in  permanent,  dark- 
red,  bulky  formations,  the  shape  of  the  nose  being  contorted  into 
various  irregular  forms.  Duhring  reports  a  case  in  which  the  nose 
was  the  size  of  the  patient's  fist  (rhinophyma). 

Diagnosis.  The  characteristics  of  the  disease  are  so  marked, 
consisting  of  rosacea — the  dilated  and  hypertrophic  blood-vessels — 
with  papular  and  pustular  acne  superadded,  that  an  error  can  hardly 
occur. 

Lupus  vulgaris  bears  some  resemblance  to  acne  rosacea,  as  it  is 
apt  to  develop  about  the  face,  and  especially  the  nose  ;  but  the  pap- 
ules, tubercles,  and  pustules  of  lupus  vulgaris  soon  ulcerate,  followed 
by  crusts  and  cicatrices,  which  never  occur  in  acne  rosacea. 

Lupus  erythematosus  may  be  confounded  with  acne  rosacea  if  it 
occurs  upon  the  end  of  the  nose ;  but  in  the  former  the  skin  is  harsh 

37 


578  PRACTICE    OF    MEDICINE. 

and  covered  with  adherent  whitish  and  yellowish  scales  connected 
with  the  openings  of  the  sebaceous  follicles,  which  is  never  the  case 
in  acne  rosacea. 

Frostbite  resembles  the  first  stage  of  acne  rosacea,  but  the  history 
of  the  two  conditions  soon  determines  the  diagnosis. 

Prognosis.  Favorable,  if  treatment  be  instituted  during  the  first 
stage.  After  hypertrophy  has  occurred  but  little  can  be  accom- 
plished. 

Treatment.  The  cause  is  to  be  sought  for  and  removed,  and  the 
general  health  promoted.  The  use  of  all  alcoholic  drinks  to  be  inter- 
dicted, and  only  small  amounts  of  tea  and  colTee  are  to  be  allowed. 
In  the  first  stage  good  results  may  be  obtained  from  the  following 
formula,  known  as  "  Kummerfeld's  lotion  "  : 

R.     Sulphur,  prrecipitat., 3  iv  16.      Gm. 

Pulv.  camphors;, K""-  ^  °-^    ^"^• 

Pulv.  tragacanthse, ►)]  1.3    Gm. 

Aqure  calcis, f  .^  ij  60.      Cc. 

Aquje  rosK, f5ij  60.      Cc.        M. 

SiG. — Shake  the  bottle  before  using  and  apply  every  few  hours. 

Or— 

U.      Hydrargyri  chlor.  corrosiv. ,       .    .     gr.  ij  o.  l3Gm. 

Ung.  petrolei, ,^  j  30.       Gm. 

SiG. — Apply  thoroughly. 

Or,  the  following,  suggested  by  G.  H.  Fox: 

JJ.     Chrysarobini, .^^ss  2.       Gm. 

CoUodii, f5J  30.       Cc. 

SiG. — Put  a  brush  through  the  cork  and  paint  lesions  every  evening. 

For  the  second  stage  stronger  applications  are  usually  required. 
The  dilated  capillaries  should  be  incised  with  a  sharp  knife,  in  the 
hope  that  adhesive  inflammation  may  close  the  calibre  of  the  vessels, 
cold  water  compresses  being  used  to  control  the  bleeding,  a  few  of 
the  dilated  vessels  being  thus  treated  every  day  or  two,  until  all  have 
been  incised.  Another  plan  is  to  paint  the  affected  parts,  once  or 
twice  a  week,  with  a  ten-  to  twenty-grain  solution  of /^/^.y^ya,  following 
its  application  with  an  emollient  poultice.  Electrolysis  has  also  been 
recommended. 

I  have  had  excellent  results  in  two  typical  tases  from  a  long  course 
of  the  extract  of  thyroid  gland  gr.  j-ij  (0.065-0.13  Gm.). 


DISEASES    OF   THE   SKIN.  579 


PSORIASIS. 


Synonyms.     Lepra  ;  alphos  ;  psora  ;  English  leprosy. 

Definition.  A  chronic  affection  of  the  skin,  characterized  by 
reddish,  more  or  less  thickened  and  elevated,  dry,  inflammatory,  and 
somewhat  wrinkled  patches,  variable  as  to  size,  shape,  and  number, 
and  covered  with  abundant  whitish  or  grayish  colored,  imbricated 
scales.     It  is  not  contagious. 

Cause.  Not  known.  The  source  of  the  affection  is,  no  doubt, 
limited  to  the  skin  itself,  as  no  external  or  internal  factors  can  produce 
it.  It  occurs  in  the  robust  and  in  the  feeble,  and  in  males  and  females. 
It  usually  first  appears  in  early  life,  and  recurs  at  intervals  for  years. 

Pathology.  "  The  disease  is  essentially  a  hyperplasia  of  the 
normal  constituents  of  the  Malpighian  layer  (mucous  layer).  The  in- 
crease takes  place  chiefly  in  the  interpapillary  portion  of  the  layer,  the 
growth  of  which  downward  causes  an  apparent  increase  in  the  size  of 
the  papillae  of  the  corium,  which,  however,  on  closer  examination,  are 
found  not  to  be  enlarged.  In  the  later  stages  of  the  disease  the  more 
superficial  blood-vessels  of  the  corium  become  dilated,  a  more  or  less 
considerable  emigration  of  the  white  blood-corpuscles  takes  place,  and 
the  immediate  neighborhood  of  the  vessels,  together  with  the  connec- 
tive tissue  of  the  corium,  becomes  the  seat  of  a  round-cell  infiltration, 
which,  with  the  effusion  of  serum,  separates  the  connective-tissue 
bundles  and  fibers  into  an  open  meshwork.  During  the  period  of 
disappearance  of  the  disease  there  is  a  gradual  return  to  the  normal 
condition,  until  the  hyperplasia,  dilatation  of  the  blood-vessels,  and 
cell  infiltration  has  completely  disappeared.  The  hair  in  psoriasis  is 
affected  from  the  beginning  of  the  disease,  hyperplasia  of  the  external 
root-sheath,  the  structure  corresponding  to  the  Malpighian  layer  of  the 
epidermis,  taking  place,  with  extension  of  the  hyperplastic  structure, 
into  the  surrounding  cutis.  The  sebaceous  and  sweat  glands  are  not 
at  any  time  affected"  (Robinson). 

Symptoms.  Psoriasis  begins  as  small,  reddish  spots,  of  the  size 
of  a  pin's  head,  which  immediately  become  covered  with  scanty  or 
abundant  whitish  or  grayish  ijnbricated  so-zXt?,.  The  spots  gradually 
increase  in  diameter,  forming  patches  of  various  sizes  and  shapes. 

If  one  of  the  scales  be  detached  by  means  of  the  finger-nail,  it  will 
be  found  to  adhere  quite  firmly  to  the  skin,  and  to  be  about  the 


580  PRACTICE   OK   MKDICINE, 

thickness  of  a  card-board.  If  the  reddish  patch  thus  made  bare  be 
pinched  up  between  the  finger  and  thumb,  and  compared  with  a  sim- 
ilar pinch  of  the  healthy  skin,  its  inflammatory  thickening  will  be  dis- 
cerned. There  is  no  luatery  discharge  nt  atiy  time.  The  skin  between 
the  patches  is  perfectly  healthy. 

While  the  anatomical  lesions  are  always  identical,  the  eruption 
assumes  such  features,  in  the  size  and  shape  of  the  patches,  to  give  rise 
to  special  names : 

Psoriasis punciaia.  The  eruption  occurs  as  small,  rounded  patches, 
about  the  size  of  a  pin's  head.  This  is  a  rare  variety,  as  the  lesion 
rapidly  increases  in  size. 

Psoriasis  guttata.  The  eruption  occurs  in  the  form  and  size  of 
drops,  and  when  covered  with  scales  gives  the  skin  the  appearance 
of  having  been  splashed  with  mortar.     A  quite  frequent  variety. 

Psoriasis  tiummidaris.  The  eruption  resembles  variously  sized 
coins.     This  is  frequently  as  large  as  the  patches  grow. 

Psoriasis  circinata.  The  eruption  about  the  size  of  the  former 
variety,  the  centre  clearing  away,  leaving  the  skin  normal,  although 
it  may  continue  to  enlarge  at  the  periphery,  after  the  manner  oi  tinea 
circitiata. 

Psoriasis  gyr at  a.  The  eruption  in  wavy  lines,  of  the  width  of  about 
half  an  inch,  resembling  circles  and  semicircles.  This  variety  is  a 
continuation  of  the  former,  from  the  joining  of  the  patches  of  psoriasis 
circinata. 

Psoriasis  diffusa.  The  patches  of  eruption  are  large  and  of  irregu- 
lar shape,  covering  a  considerable  amount  of  surface.  This  variety 
occurs  more  frequently  on  the  front  of  the  leg  and  the  outer  aspect  of 
the  forearm. 

Psoriasis  palmaris  et  plantaris.  In  these  regions  the  eruption  is 
characterized  by  larger,  thicker,  and  less  lustrous  scales,  and  by  the 
occurrence  of  deep  and  painful  fissures,  from  which  exudes  either  a 
serous  or  sanguineous  fluid. 

Psoriasis  ungiiiiiin.  In  psoriasis  of  the  nails  they  become  thick- 
ened, opaque,  grayish  in  color,  deeply  grooved  transversely,  and 
often  pitted,  and  in  rare  cases  the  nails  are  replaced  by  a  scaly 
incrustation. 

Any  portion  of  the  body  is  liable  to  be  attacked  with  psoriasis.  The 
only  discomfort  the  patient  suffers  is  from  the  itching,  which  at  times 
is  very  severe  and  distressing. 


DISEASES   OF  THE   SKIN.  581 

Diagnosis.  A  typical  attack  of  psoriasis  presents  no  difficulty  in 
diagnosis.  There  are  a  few  affections,  however,  which  may  be  con- 
founding in  irregular  cases. 

Eczema  squamosum  occurring  upon  the  legs  closely  resembles 
psoriasis,  and  if  the  former  has  been  attended  with  a  very  small 
amount  of  moisture  and  the  latter  has  been  considerably  irritated  by 
scratching,  the  diagnosis  will  be  very  difficult. 

The  papulo-squamous  syphiloderm  and  psoriasis  are  frequently 
mistaken  for  each  other,  the  diagnosis  at  times  being  extremely 
difficult. 

Tinea  circinata  and  psoriasis  circinata  resemble  each  other,  but 
the  patches  of  the  latter  are  less  inflammatory,  red,  and  infiltrated, 
and  the  scales  more  abundant  and  larger  than  the  former.  Tinea 
circinata  is  usually  the  result  of  contagion,  and  the  scales  contain  a 
fungus. 

Seborrhoea  of  the  scalp  and  psoriasis  of  the  same  region  are 
frequently  confounded.  In  the  former  the  scalp  is  paler,  the  scales 
are  finer,  smaller,  more  generally  diffused,  of  a  grayish  or  yellowish 
color,  and  greasy,  sebaceous  character.  Psoriasis  of  the  scalp  is  in 
patches,  which  are  reddish  and  infiltrated,  and  there  are  almost 
always  patches  of  the  disease  on  other  parts  of  the  body. 

Prognosis.  An  attack  can  easily  be  removed,  but  it  is  always 
apt  to  return,  so  that  a  permanent  cure  can  never  be  promised. 

Treatment.  Constitutional  and  local  measures  are  both  needed 
in  the  majority  of  attacks  of  psoriasis. 

Constituiio7ial  treaUnent.  Attention  to  the  general  health,  remov- 
ing all  deleterious  influences,  such  as  dyspepsia,  constipation,  lithia- 
sis,  malaria,  anaemia,  or  catarrhs. 

Among  the  most  valuable  remedies  used  in  the  treatment  of  psoriasis 
is  arse7ticnJ7t,  given  in  full  doses  for  a  long  period.  It  is  to  be  kept 
in  mind,  however,  that  the  drug  is  contraindicated  in  all  acute  and 
inflammatory  cases. 

Potassii  iodidum  in  full  doses,  tinctura  cantharides,  quinina, 
phosphorus,  acidum  carbolicutn,  and  pix  liquida  have  all  been  used 
with  variable  success,  often  what  has  proved  successful  for  one  patient 
being  useless  in  another. 

Local  treatment.  The  character  of  the  local  measures  should  de- 
pend upon  the  duration  of  the  disease,  its  extent,  location,  and  obsti- 
nacy. 


582  PRACTICE    OF    MEDICINE. 

The  first  step  is  the  thorough  removal  of  the  scales.  This  may  be 
accomplished  by  repeated  washings  with  soft  soap  and  water,  or 
plain  or  alkaline  baths  or  medicated  washes. 

In  the  early  stage,  with  highly  inflammatory  symptoms,  soothing 
applications,  such  as  water  dressings,  or  inunctions  with  oils,  of  which 
oletim  olives  rubbed  over  the  patch  several  times  each  day  is  very 
serviceable. 

For  chronic  cases  nothing  seems  comparable  with  the  following 
formula,  suggested  by  Dr.  G.  H.  Fox  : 

R.      Chrysarobini gr.  x-xx-^j       0.65-1.3-40111. 

/Etheris  et  alcoholis,  ....     ad    q.  s.  q.  s. 

Collodii, f^5J  30.  Cc. 

SiG. — Rub  the  clirysarobin  with  a  little  alcohol  and  ether,  and  add  to 
the  collodion. 

If  a  camel's-hair  pencil  be  placed  through  the  cork,  this  may  be 
painted  over  the  affected  patch  after  the  removal  of  the  scales,  and 
after  drying  it  will  not  stain  the  clothing.  Care  must  be  exercised 
that  the  strength  be  not  too  great,  or  dermatitis  may  result. 

The  following  formula  I  have  never  seen  fail : 

R  .     Chrysarobini, gr.  x-xv-xxx     0.6-1-2  Gm. 

Ung.  petrolei, 5J  30.  Gm. 

SiG. — Apply  to  each  spot  twice  daily. 

Jamieson  recommends  the  following : 

li.     Ammonii  carbonat., ^ij  8.  Gm. 

Adeps  lanae  hydrosus,    .    .    .    .     ziv  16.   Gm. 

Ceratigaleni, ^d    5J  ad  30.    Gm.  M. 

SiG. — Apply  three  times  a  day,  followed  by  a  warm  bath  at  night. 

Dr.  Bramwell,  of  Edinburgh,  reports  remarkable  success  in  the 
cure  of  psoriasis  by  the  internal  administration  of  "  a  quarter  of  a  raw 
thyroid  gland,  finely  minced  and  concealed  in  rice-paper,  daily," 
"  and  no  application  whatever  was  made  locally."  I  have  had 
excellent  results  in  six  cases  with  the  dried  gland  in  doses  of  from 
gr.  j-iij  (0.065-0.2  Gm.)  three  times  daily. 

Among  local  remedies  recommended  are  :  pix  liquida,  saponis  viri- 
dis,  creasotum,  sulphur,  and  aciduin  carbolicum. 


DISEASES    OF   THE   SKIN.  '  583 

HYPERTROPHIES  OF  THE  SKIN. 

LENTIGO. 

Synonym.    Freckles. 

Definition.  A  pigmentary  deposit  of  the  skin,  characterized  by 
irregularly  shaped,  pin-head  or  pea-sized,  yellowish,  brownish,  or 
blackish  spots  occurring  for  the  most  part  about  the  face  and  back  of 
the  hands. 

Cause.  In  the  majority  of  instances  exposure  to  the  sun  is  the 
exciting  cause. 

Pathology.  In  anatomical  structure  freckles  consist  of  a  circum- 
scribed, increased  amount  of  normal  pigment,  differing  from  chloasma 
only  in  the  peculiar  form  and  size  of  the  deposit. 

Symptoms.  The  number  of  "freckles  "  varies  from  a  very  few 
to  immense  numbers.  They  occur  as  brownish  or  yellowish-brown, 
small,  roundish,  irregular  spots,  most  commonly  upon  the  face  and 
hands.  Rarely  the  number  is  very  great,  and  they  give  to  the  skin 
an  uncleanly  appearance.  They  are  apt  to  occur  at  all  ages,  but 
rarely  before  the  third  year. 

They  are  unattended  with  itching  or  other  subjective  symptoms. 

Prognosis.  Usually  favorable.  Their  course,  when  left  to  them- 
selves, is  chronic,  lasting  for  years  or  a  life-time.  They  ordinarily 
appear  in  the  summer,  fading  away  as  cold  weather  approaches,  to 
return  the  following  summer. 

Treatment.  The  following  application  has  usually  been  success- 
ful: 

U.     Hydrargyri  chlor.  corrosiv.,  .    .    gr.  iij  0.2  Gm. 

Acid,  hydrochlorici  dil  ,    .    .    .  f ^j  4.     Cc. 

Alcoholis, f.^j  30.      Cc. 

Glycerini, f^^^  ^5'     ^^' 

Aquae  ros£E, adfgiv  ad  120.     Cc.  M. 

SiG. — Apply  at  bedtime,  and  remove  with  soap  and  water  in  the  morning. 

CHLOASMA. 

Synonyms.    Liver  spots ;  moth. 

Definition.  A  pigmentary  discoloration  of  the  skin,  character- 
ized by  variously  sized  and  shaped,  more  or  less  defined,  smooth 
patches,  or  of  a  discoloration,  yellowish,  brownish,  or  blackish  in  color. 


584  PRACTICE    OF    MEDICINE. 

Cause.  The  etiology  of  chloasma  depends  upon  whether  the 
pigmentation  is  idiopathic  or  symptomatic  in  its  occurrence. 

Idiopathic  chloasma  results  from  the  irritation  of  long-continued 
scratching,  such  as  is  practised  in  severe  eczema  or  pediculosis,  the 
application  of  blisters  and  sinapisms,  heat,  the  direct  rays  of  the  sun, 
and  various  medicinal  and  chemical  substances,  such  as  follows  the 
prolonged  use  of  argentum  (argyria). 

Symptomatic  chloasma  occurs  in  connection  with  cancer,  malaria, 
tuberculosis,  disease  of  the  suprarenal  capsule  (Addison's  disease), 
disease  of  the  womb,  pregnancy  (chloasma  uterinum),  neurotic  dis- 
turbances, dementia,  anaemia,  and  chlorosis. 

Pathology.  The  affection  is  an  increased  deposit  of  the  normal 
pigment  having  its  seat  in  the  mucous  layer  of  the  epidermis.  The 
deposition  of  the  pigment  is  the  result  of  a  nervous  derangement, 
possibly  of  the  trophic  system. 

Symptoms.  Chloasma  is  simply  a  discoloration  of  the  skin,  un- 
attended by  alteration  of  the  surface.  The  patches  vary  in  size  and 
shape ;  they  may  be  as  minute  as  a  coin  or  as  large  as  the  hand,  or 
much  larger,  even  to  a  universal  discoloration  of  the  entire  surface, 
and  they  may  be  roundish  or  irregular  in  outline.  The  usual  color  is 
yellcwish,  brownish,  or  viuddy,  or  even  blackish  {melasma  7nelano- 
dermd). 

In  Addison  s  disease,  of  a  typical  character,  "the  coloration  is 
brownish,  with  an  olive-greenish  or  bronze  tint,  and  is  general, 
although,  as  a  rule,  especially  pronounced  upon  regions  having  a  dis- 
position to  normal  increase  of  pigment,  as  the  face,  backs  of  the 
hands,  axillae,  areolae  of  the  nipples,  and  the  genital  organs ;  the  hair, 
also,  may  become  darkened.  Gaskoin  reports  a  case,  occurring 
in  a  woman  aged  forty-five,  where  the  patch,  situated  on  the  cheek, 
near  the  nose,  was  intensely  dark.  It  had  existed  nine  years.  The 
color  of  the  hair  had,  fifteen  years  previously,  changed  from  carroty- 
red  to  black.     For  additional  symptoms  see  page  203. 

In  argyria,  or  discoloration  of  the  skin  resulting  from  the  internal 
use  of  nitrate  of  silver,  the  color  is  a  bluish,  bluish-gray,  slate,  bronze, 
or  blackish,  varying  as  to  the  shade.  It  occurs  over  the  surface 
generally,  but  is  more  pronounced  upon  parts  exposed,  as  the  face 
and  hands. 

Chloasma  uterinum,  occurs  most  frequently  between  the  ages  of 
twenty-five   and  fifty,  seldom  after  the  menopause,  caused,  in  the 


DISEASES   OF   THE   SKIN.  585 

greater  number  of  instances,  by  changes,  physiological  and  patho- 
logical, which  take  place  in  connection  with  the  uterus.  It  is  seen 
in  the  married  and  single,  although  much  commoner  in  the  former. 
Pregnancy  is  the  most  frequent  cause,  although  also  associated  with 
either  dysmenorrhoea,  chlorosis,  anaemia,  or  hysteria.  It  is  seen  in 
the  mildest  degree  about  the  eyelids,  especially  during  the  menstrual 
epoch,  as  a  duskiness  or  swarthiness  of  the  complexion,  either  lasting 
a  few  days  or  being  permanent.  As  usually  encountered,  however 
chloasma  of  this  variety  consists  in  the  presence  of  one  or  several 
patches,  appearing  generally  about  the  forehead  orother  parts  of 
the  face,  upon  the  trunk,  about  the  nipples,  and  upon  the  abdomen. 
Rarely  the  entire  face  is  covered  with  a  discoloration,  resembling  a 
mask.  Cases  are  recorded  in  which  the  pigmentary  deposit  was 
general,  resembling  Addison's  disease. 

Diagnosis.  Tinea  versicolor  and  chloasma  resemble  each  other 
in  the  color  of  the  patches,  but  otherwise  they  have  nothing  in  com- 
mon. Tinea  versicolor  occurs  on  the  trunk,  while  chloasma  occurs 
upon  the  face  and  about  the  nipples,  and  in  cases  the  result  of  preg- 
nancy about  the  umbilicus,  except  in  those  comparatively  rare 
instances  in  which  the  discoloration  is  diffused.  The  patches  of 
chloasma  are  smooth,  those  of  tinea  versicolor  furfuraceous,  as  can 
readily  be  demonstrated  by  gently  scraping  the  discoloration  with  the 
finger-nail. 

Prognosis.  Unless  the  result  of  Addison's  disease,  the  prolonged 
use  of  argentum,  tuberculosis,  or  cancer,  favorable. 

Treatment.  Chloasma  not  the  result  of  organic  disease  or  the 
use  of  argentum  is  usually  removed  by  either  of  the  following 
formulae : 

R.      Hydrargyri  chloridi  corrosiv. ,     .     gr.  viiss  0.5  Gm. 

Zinci  sulphat., gss  2.     Gm. 

Plumbi  acetatis, J5ss  2.     Gm. 

Aquas, f^iv  120.     Cc.  M. 

SiG. — Lotion.     Apply  morning  and  evening.  (Hardy.) 

Or— 

R .     Hydrargyri  chloridi  corrosiv.,     .    gr.  vj  0.4  Gm. 

Acidi  acetici  dil.,      ......  f.^  ij  8.     Cc. 

Boracis,      . ^  ij  2.6  Gm. 

Aquce  rosse, f^iv  120.    Cc.             M. 

SiG. — Lotion.      Apply  twice  daily.      (Bulkley.) 

50 


5Srt  PRACTICE    OK    MKDICINE. 

Or— 

R.     Hyfliaip;.  aniinoniat., 5J  4-  Gm. 

Bisimiihi  siibnit., 3J  4.  Gm. 

Ung.  pelrolei, 5J  30.  Gm.               M. 

SlG. — Apply  frequently. 

For  argyria  the  first  step  is  the  withdrawal  of  the  argentum,  and, 
according  to  Prof.  Bartholow,  "  a  persistent  and  long-continued  use 
o{ potassiiiodidiim  and  sodii  hypophosphitis  has,  in  a  few  fortunate  in- 
stances, caused  the  absorption  and  excretion  of  the  silver  deposits." 
The  action  of  these  systemic  remedies  for  the  discoloration  may  be 
aided  by  baths  of  the  hyposidphites,  and  by  the  cautious  use  of  lotions 
containing  potassii  cyatiidum,  which  possesses  a  decided  solvent 
power  over  the  silver  deposits. 


CALLOSITAS. 

Synonyms.     Tyloma  ;  callus  ;  callosity. 

Definition.  Callositas,  or  tyloma,  consists  in  the  development  of 
a  hard  or  horny,  thickened  patch  of  skin,  variable  in  extent,  and  of 
a  grayish,  yellowish,  or  brownish  color,  and  unattended  by  pain. 
The  most  frequent  location  is  upon  the  hands  and  feet. 

Causes.  The  result  of  pressure  or  friction,  as  in  the  case  of  the 
hands  of  the  mechanic,  the  effect  of  his  tools;  or,  if  upon  the  foot, 
the  result  of  ill-fitting  shoes  or  from  long  marches.  Callosities  are 
also  seen  upon  the  fingers  of  violin,  banjo,  and  harp  players. 

Pathology.  A  hypertrophy  of  the  horny  layer  of  the  skin,  the 
corium  remaining  normal.  The  cells  of  the  epidermis  become  so 
closely  packed  together.as  often  to  simulate  horn  substance. 

Symptoms.  Callositas  consists  in  an  increase  in  the  thickness  of 
the  skin  of  the  affected  part,  presenting  a  firm,  dense,  more  or  less 
circumscribed  structure,  the  extent  of  hardness  varying  considerably, 
sometimes  being  horny.  The  patch  of  hardness  is  generally  about 
the  size  of  a  coin,  roundish  in  shape,  and  somewhat  elevated  above 
the  surrounding  skin.  The  color  of  the  patch  may  be  either  grayish, 
yellowish,  or  brownish. 

Callosities  are  usually  upon  the  palms,  fingers,  soles,  and  toes, 
although  other  parts,  if  exposed  to  the  cause,  may  also  be  the  seat. 
At  times  great  pain  and  discomfort  are  experienced  from  the  growth. 


DISEASES   OF  THE  SKIN.  587 

Occasionally  callosities  are  complicated  by  hypersemia,  fissure,  acute 
inflammation,  abscess,  erysipelas,  and  serve  readily  as  foci  for  such 
cutaneous  diseases  as  eczema  and  psoriasis. 

Course.  Their  formation  and  development  is  always  slow  and 
gradual.     If  the  cause  be  removed,  the  prognosis  is  favorable. 

Treatment.  If  the  removal  of  the  callous  growth  be  desirable, 
the  part  should  be  repeatedly  soaked  in  warm  water,  or  a  poultice 
applied,  or  warmed  oil  kept  in  contact  by  compresses  of  flannel, 
which  will  soften  the  induration  and  permit  its  removal  by  paring 
or  scraping,  layer  by  layer,  with  a  sharp  knife.  Success  has  been 
reported  from  the  use  of  a  plaster  of  india-rubber  containing  acidum 
salicylicu7n.  Painting  with  diluted  tinctura  iodi  once  daily  is  often 
serviceable. 


CLAVUS. 

Synonym.    Corn. 

Definition.  A  corn  is  a  small,  circumscribed,  usually  flat,  deep- 
seated  hypertrophy  of  the  epidermis,  having  a  horny  feel,  projecting 
slightly  from  the  skin,  painful  upon  pressure,  situated  for  the  most 
part  about  the  toes. 

Cause.  Continued  pressure  or  friction,  usually  from  ill-fitting  or 
tight  boots  or  shoes. 

Pathology.  A  clavus  consists  of  a  circumscribed,  excessive 
hypertrophy  of  the  epidermis,  of  the  same  character  as  occurs  in 
callosity,  and  of  a  central  portion — the  core.  The  core  extends 
deeply  into  the  tissues,  in  the  shape  of  an  inverted  cone,  the  base 
of  the  cone  being  directed  outward  and  appearing  upon  the  surface 
as  a  roundish  elevation,  its  apex  resting  upon  the  papillary  layer  of 
the  corium.  The  core  of  a  clavus  consists  of  a  whitish,  opaque,  firm, 
tenacious  body,  composed  of  epidermic  cells,  arranged  in  concentric 
laminse. 

The  pain  attending  the  presence  of  corns  results  from  pressure 
upon  the  true  skin  by  the  hard  core,  causing  irritation  of  the  nerve- 
filaments  of  the  papillee. 

Corns  existing  between  two  toes  are  constantly  bathed  with  the 
moisture  of  the  part,  which  macerates  and  softens  the  formation, 
which  thus  receives  the  name  of  soft  corn,  in  contradistinction  to  the 
hard  corn. 


588  PRACTICE    OF    MEDICINE. 

Symptoms.  Until  the  growth  attains  a  considerable  size  no  dis- 
comfort, as  a  rule,  is  felt.  After,  however,  its  depth  has  reached  the 
true  sk\n,  />am,  of  an  intermittent  character,  aggravated  by  pressure, 
is  the  chief  symptom. 

Corns  are  often  weather  sensitive,  being  unusually  painful  before, 
during,  or  after  the  occurrence  of  storms,  and  should,  therefore,  not 
be  confounded  with  gouty  or  rheumatic  deposits  below  the  skin. 

Treatment.  If  freedom  from  these  annoying  formations  be  de- 
sired, the  use  of  a  properly  fitting  foot-covering  must  be  practised. 
The  pressure  which  results  in  the  severe  pain  is  limited  by  the  use  of 
the  ringed  protective  plasters  in  common  use. 

To  remove  the  corn,  soaking  with  hot  water,  or  a  poultice  kept  in 
contact  over  night,  will  soften  the  part  and  permit  of  its  ready  removal 
with  the  knife. 

For  so//  corns,  the  application  of  argenti  nitras,  in  solid  stick  form, 
is  highly  spoken  of,  to  be  used  after  the  growth  has  been  sufficiently 
softened.     The  following  application  will  usually  remove  the  "  corn  "  : 

R.     Acidi  salicylic!, 3  iss  6.     Gm. 

Ext.  cannab.  indicce, gr-  x  0.6  Gm. 

Collodii, fij  30.    Cc.  M. 

SiG — Painted  over  corn  at  night  and  scraped  off  in  the  morning. 


VERRUCA. 

Synonym.    Wart. 

Definition.  A  wart  consists  of  a  circumscribed  hypertrophy  of 
the  papillary  layer,  with  more  or  less  epidermal  accumulation,  char- 
acterized by  the  appearance  of  a  hard  or  soft,  rounded,  flat,  or  acumi- 
nated formation,  of  variable  size. 

Varieties.  The  following  varieties  have  chiefly  a  descriptive 
value  :  verruca  vulgaris  ;  verruca  plana  ;  verruca  Jiliformis  ;  verruca 
digit ata  ;  verruca  acuminata. 

Cause.  Obscure.  The  various  assigned  causes  are  probably  in- 
capable of  producing  the  affection. 

Pathology.  While  the  anatomy  of  warts  differs  somewhat  accord- 
ing to  their  variety,  in  all  forms  there  exists  as  a  basis  of  their  forma- 
tion a  connective-tissue  growth  from  which  the  papillary  hypertrophy 
takes  place.  The  interior  of  the  growth  is  supplied  by  one  or  more 
vascular  loops,  from  which  their  vitality  is  obtained. 


DISEASES    OF   THE   SKIN.  589 

Rymptnms.  The  various  forms  are  so  different  as  to  require  a 
separate  description. 

Verruca  vulgaris,  or  the  ordinary  wart  commonly  seen  on  the 
hands,  consists  of  a  small,  circumscribed,  elevated  growth,  having  a 
broad  base  seated  securely  upon  the  skin.  Their  consistency  is 
either  soft  or  firm,  the  surface  smooth  or  rough,  the  color  that  of  the 
surrounding  skin,  or  yellowish,  brownish,  or  even  blackish.  They 
may  develop  upon  any  region  of  the  body,  but  are  most  commonly 
seen  upon  the  hands  and  fingers. 

Verrtica  plana  differs  from  the  vulgaris  in  being  flat  and  broad  in 
form,  and  but  slightly  raised  above  the  level  of  the  surrounding  skin. 
Their  most  common  location  is  either  on  the  back  or  forehead. 

Verruca  filiformis  assumes  the  shape  of  a  minute,  thin,  conical,  or 
thread-like  formation,  about  an  eighth  of  an  inch  in  length.  The 
most  frequent  location  is  the  face,  eyelids,  and  neck. 

Verruca  digitata  consists  of  a  slightly  elevated,  broad  formation, 
about  the  size  of  a  split  pea,  and  marked  by  a  number  of  digitations 
coming  from  its  border,  giving  an  appearance,  in  marked  cases, 
resembling  a  crab.     Their  most  frequent  site  is  upon  the  scalp. 

Verruca  acttmiftaia,  known  also  as  the  pointed  wart,  the  moist 
wart,  the  pointed  condyloma,  cauliflower  excrescence,  and  venereal 
wart,  consists  of  one  or  more  groups  of  irregularly  shaped  elevations, 
often  so  closely  packed  together  as  to  form  a  more  or  less  solid  mass 
of  vegetations  (verrucae  vegetantes).  Their  color  depends  somewhat 
upon  the  degree  of  vascularity.  Varying  from  a  pinkish,  bright  red  to 
a  purple  color.  They  occur,  for  the  most  part,  about  the  genitalia  of 
either  sex.  Upon  the  penis,  they  usually  spring  from  the  glans  and  the 
inner  surface  of  the  prepuce.  From  the  inner  surface  of  the  labia  and 
from  the  vagina  in  the  female.  They  are  also  seen  about  the  anus, 
mouth,  axillae,  umbilicus,  and  toes.  They  may  be  either  moist  or  dry, 
according  to  their  location.  About  the  genitalia,  a  yellowish,  puriform 
secretion  usually  covers  their  surface,  due  to  friction  and  maceration, 
which,  owing  to  the  heat  of  the  parts,  rapidly  decomposes,  producing 
a  highly  offensive,  penetrating,  and  disgusting  odor.  Their  size  varies 
from  that  of  a  pea  to  that  of  an  almond,  an  egg,  or  even  the  fist. 
Their  development  is  rapid,  attaining  considerable  size  in  a  few 
weeks. 

Prognosis.     Favorable. 

Treatment.     For  the  smaller  warts,  excision   by  means  of  the 


590  rUACTICE    OF   >tED»tTNE. 

knife  or  scissors  affords  the  most  satisfactory  results.  If  the  growth 
be  large,  and  likely  to  be  attended  with  considerable  hemorrhage, 
as  in  cases  of  condyloma  about  the  genitalia,  the  galvano-caustic 
wire  or  the  Paquelin  cautery  are  to  be  preferred.  Transfixing  the 
growth  in  several  directions  with  long  needles  dipped  in  a  fifty  per 
centum  solution  of  aciditvi  chromicuiii  has  been  recommended.  The 
topical  application  of  caustics,  such  as  aciduin  aceiicum,  acidum 
nilricutn,  argenti  iiitras,  ox  fcti-i  perchloridimi  is  often  satisfactory. 
I  have  been  successful  in  some  cases  by  painting  the  growth  with 
tinctura  thuja  occidentalis  until  their  size  was  considerably  reduced 
and  then  snipping  them  off  with  the  scissors.  The  following  formula 
for  warts  and  corns  is  usually  successful : 

R .     Acidi  salicylici, 3  ss  2.  Gm. 

Ext.  cannab.  indicK, p;r.  v-x  0.3-0.6  CIm. 

Collodii, fo^^~J  '5~30-  ^^-  M- 

SiG. — Apply  once  or  twice  daily. 

An  excellent  formula  is — 

li .     Acidi  salicylici, 

Acidi  borici, aa  gr.  xv  aa  I.     Gm. 

Hydrargyri  chlor.  mitis,     .    .    .    .    gr.  x  0.6  Gm.  M. 

SiG. — Sprinkle  over  twice  daily. 


ICHTHYOSIS. 

Synonyms.     Ichthyosis  vera  ;  fish-skin  disease. 

Definition.  Ichthyosis  is  a  congenital,  chronic  deformity  or 
hypertrophic  disease  of  the  skin,  characterized  by  dryness,  harshness, 
or  general  scaliness  of  the  skin,  or  in  the  outgrowth  of  larger  masses 
of  a  corneous  consistency. 

Varieties.     Ichthyosis  simplex  ;  ichthyosis  hystrix. 

Cause.  Often  hereditary,  but  not  in  all  cases.  It  is  to  be  re- 
garded as  an  affection  which  is  born  with  the  individual,  although  it 
does  not  usually  manifest  itself  until  after  the  first  or  second  year  of 
life. 

Pathology.  "  The  diseased  or,  better,  deformed  skin  is  found 
microscopically  to  be  hypertrophied  in  various  degrees,  according  to 
the  development  of  the  malady  ;  the  proliferation  of  its  elements 
occurring  in  the  connective  tissue,   papillae,  stratum  corneum,  and 


DISEASES   OF   THE   SKIN,  591 

blood-vessels.  In  well-marked  cases  of  ichthyosis  hystrix  the 
elongated  papillae  are  surrounded  by  dense  cones  of  the  horny  layer 
of  the  epidermis,  more  or  less  concentrically  disposed,  with  sclerosis 
of  the  connective  tissue  and  a  relatively  unchanged  rete.  In  this  last 
particular  the  dense  plaque  of  ichthyosis  differs  in  texture  from  the 
wart"  (Hyde). 

Symptoms.  Ichthyosis  displays  wide  variation  in  its  symp- 
toms. In  one  individual  it  amounts  to  slight  inconvenience,  while 
in  another  it  may  manifest  itself  in  so  pronounced  a  manner  as 
to  be  the  source  of  great  discomfort  and  deformity.  The  two  varieties 
named  represent  merely  accentuated  types  of  the  disorder,  rare  in  its 
fullest  development,  and,  in  its  slightest,  much  more  common  than  is 
generally  believed. 

A  simple  dryness  and  harshness  of  the  skin,  with  only  slight  fur- 
furaceous  exfoliation,  is  termed  xeroderma. 

Ichthyosis  simplex  is  the  more  common  variety,  consisting  of  a 
harsh,  dry  condition  of  the  whole  surface,  accompanied  by  the  pro- 
duction of  variously  sized  and  shaped  reticulated  scales,  either  small, 
thin,  and  furfuraceous,  like  bran,  or  large  and  thick,  resembling  fish- 
scales.  Upon  the  extremities  the  scales  usually  form  diamond-shaped 
or  polygonal  plates,  separated  from  one  another  by  furrows  or  lines 
which  extend  down  to  the  normal  skin.  In  color  the  scales  are  either 
whitish,  grayish,  or  yellowish,  and  often  have  a  silvery  or  glistening 
appearance.  Rarely  the  color  is  olive-green  or  blackish  (ichthyosis 
nigricans').  The  amount  of  scaling  depends  upon  the  age  of  the 
patient  and  the  duration  and  severity  of  the  disease. 

Ichthyosis  hystrix.  With  or  without  the  development  of  the  above 
variety,  in  this,  the  hypertrophy  of  the  skin  may  occur  in  circum- 
scribed patches  or  large  areas,  consisting  of  irregularly  shaped  ver- 
rucous, corneous,  corrugated,  wrinkled,  or  rugous  masses,  usually 
darker  in  color  than  those  of  the  simple  variety.  They  may  occur 
upon  the  arms,  as  solid,  warty  patches,  or  upon  the  back,  in  the  form 
of  elongated,  linear  patches.  Thej''  may  constitute  roughened,  corru- 
gated, papillary  growths,  or  uneven,  horny,  blunt,  or  pointed,  spinous, 
warty  formations.  In  the  latter  case  the  elevations  may  reach  several 
lines  or  more,  and  stand  out  from  the  skin  like  quills  upon  the  back 
of  a  porcupine — hence  the  name  hystrix.  The  amount  and  extent  of 
the  hypertrophy  varies  ;  the  older  the  patient,  the  more  highly  devel- 
oped it  will  usually  be. 


502  PRACTICE    OF    MEDICINE. 

Course.  Lhthyosis  simplex  may  involve  the  entire  surface  uni- 
formly or  appear  more  marked  on  the  extremities,  from  the  hips  to 
the  ankles  and  the  arms  and  forearms.  The  affection  is  always 
worse  in  winter  than  in  summer,  the  increased  activity  of  the  sweat 
glands  at  this  season  producing  the  most  beneficial  results.  The 
course  of  the  affection  is  essentially  chronic,  continuing  throughout 
life,  now  better,  now  worse.     Slight  itching  usually  occurs. 

Diagnosis.  The  characteristics  of  the  affection  are  so  peculiar 
that  an  error  in  diagnosis  is  hardly  possible.  It  is  to  be  distinguished 
from  the  inflammatory  affections  of  the  skin  which  terminate  in  des- 
quamation by  the  absence  of  any  history  of  inflammation. 

Prognosis.  While  much  can  be  done  to  alleviate  the  affection, 
the  prognosis  is  unfavorable  as  regards  permanent  relief. 

Treatment.  Local  measures  are  alone  of  value  for  ichthyosis. 
The  maceration  of  the  accumulated  masses  of  epithelial  hypertrophy 
is  accomplished  by  water-baths,  either  simple  or  medicated.  The 
relief  thus  afforded  the  patient,  while  temporary,  is  comforting. 
Duhring  says :  "  It  may  be  stated,  then,  that,  as  a  rule,  the  more  fre- 
quently the  ichthyotic  patient  bathes,  and  the  longer  he  is  able  to 
remain  in  the  water,  the  less  will  the  deformity  show  itself."  Vapor 
and  alkaline  baths  are  also  serviceable.  Another  valuable  agent  is 
sapo  mollis  in  conjunction  with  baths,  or  alone,  as  a  discutient.  '  For 
severe  cases,  "  a  sufficient  quantity  is  to  be  rubbed  into  the  skin  twice 
daily  for  four  or  six  days,  during  which  period  the  patient  is  to  refrain 
from  bathing.  A  bath  is  first  to  be  taken  four  or  five  days  after  the 
last  rubbing,  when,  in  fact,  the  epidermis  has  begun  to  peel  off;  after- 
ward inunction  with  a  simple  ointment  is  to  be  applied,  in  order  to 
prevent  fissuring  of  the  new  skin. 

The  following  is  a  useful  formula : 

R.     Adepsbenzoat., 3J  30.     Gm. 

Glycerini, Tr\^xl  2.6  Cc. 

Ung.  petrolci, 555  15.     Gm.  M. 

SiG. — Apply  daily,  after  washing  or  bathing. 

Or— 

R.     Potassii  iodidi, gr-  xx  1.3  Gm. 

Olei  bubuli, f,|ss  15.    Cc. 

Adeps 5  ss  15.     Gm. 

Glycerini, f  3  ij  8.     Cc.  M. 

SiG. — Apply  after  bathing.     (Milton.) 


DISEASES   OF   THE   SKIN.  593 

PARASITIC  DISEASES    OF  THE   SKIN. 

TINEA  FAVOSA. 

Synonyms.  Favus  ;  porrigo  favosa ;  honeycombed  ringworm  ; 
crusted  ringworm. 

Definition.  A  contagious  affection  of  the  skin,  due  to  a  vegetable 
parasite — Achorion  Schonleinii ;  characterized  by  the  development  of 
either  discrete  or  confluent,  small,  circular,  cup-shaped,  pale-yellow, 
friable  crusts,  usually  perforated  by  hairs. 

Cause.  The  presence  and  growth  of  a  vegetable  parasite  known 
as  the  Achorion  Schonleinii  is  the  cause  of  tinea  favosa.  It  is  com- 
moner in  children  than  in  adults,  attacking  the  former  in  the  first 
place  either  de  novo  or  through  direct  contagion,  and  is  from  them 
communicated  to  adults.  It  is  a  disease  confined  almost  exclusively 
to  the  lower  classes. 

Pathology.  Tinea  favosa  may  have  its  seat  either  in  the  hair- 
follicles  and  hair,  or  upon  the  surface  of  the  skin  or  the  nails  ;  the 
former,  however,  are  the  structures  most  frequently  involved. 

It  is  purely  a  local  affection,  due  solely  to  the  presence  and  growth 
of  the  vegetable  parasite  discovered  by  Schonlein,  of  Berlin,  in  1839, 
and  named  after  him — Achorion  Schonleinii.  The  crusts  are  made 
up  almost  entirely  of  fungus,  which  is  seen,  upon  section,  with  the 
naked  eye,  to  be  composed  of  a  porous  mass  and  to  possess  a  pale- 
yellow  or  whitish  color.  Under  the  microscope  it  is  seen  to  consist  of 
both  mycelium  and  spores  in  great  quantity  and  in  all  stages  of 
development. 

Symptoms.  When  the  affection  attacks  the  hairs  and  follicles  it 
is  termed  tiiiea  favosa  pilaris  ;  when  the  epidermis,  tinea  favosa  epi- 
dermis ;  and  when  the  nails,  tinea  favosa  unguitim.  Rarely  all  the 
structures  may  be  attacked  at  one  and  the  same  time  ;  its  usual  seat, 
however,  is  the  scalp. 

The  disease  begins  by  the  development  of  one  or  of  several /z«- 
head  sized,  pale-yellow  crusts,  seated  about  the  hair- follicles.  In 
about  a  fortnight  these  crusts  have  increased  in  size  and  are  umbili- 
cated,  termed  \hQ  favus  cups,  are  circumscribed,  circular  in  form,  and 
very  slightly  elevated  above  the  level  of  the  skin. 

In  their  normal  condition  they  are  of  a  pale-yellow  or  sulphur- 

38 


504  PRACTICK    OK    MKDICINE.  w 

yellow  color,  but  after  a  time,  from  dust  and  other  matters,  they 
become  brownish  or  greenish  yellow  in  color.  The  number  of  crusts 
vary  from  very  few  to  immense  numbers.  The  usual  size  is  about 
that  of  a  split  pea.  In  iitica  favosa  pilaris  et  r(?//7/j  the  affection  is 
often  accompanied  by  pediculi,  while  swelling  of  the  glands  of  the 
neck  and  small  abscesses  upon  the  scalp  are  not  uncommon.  The 
hairs  become  lustreless,  opaque,  brittle,  and  at  times  split  longitudi- 
nally, and  from  atrophy  of  the  follicles  and  sebaceous  glands  perma- 
nent baldness  may  result. 

In  tinea  favosa  unguium  the  nails  become  thickened,  yellow, 
opaque,  and  brittle. 

The  disease  has  a  peculiar  odor,  resembling  that  of  mice,  or  of 
musty,  stale  straw. 

Diagnosis.  In  a  recent  case  of  characteristic  favus  cups,  the 
pale-yellow  color,  the  odor,  and  the  history  of  contagion  should  ren- 
der the  diagnosis  easy.  If  of  long  standing,  however,  and  the  favi 
destroyed  by  scratching,  some  doubt  may  exist;  but  if  a  small  frag- 
ment of  a  crubt  be  placed  upon  a  glass  slide  with  a  drop  of  liquor 
poiassa,  covered  with  a  thin  glass,  and  placed  under  a  microscope  with 
a  power  of  from  two  hundred  and  fifty  to  five  hundred  diameters,  the 
features  of  the  Achorion  Schonleinii  will  determine  the  diagnosis. 

Prognosis.  Tinea  favosa  of  the  epidermis  readily  responds  to 
treatment.  Tinea  favosa  pilaris  is  more  obstinate,  and  if  of  long 
duration,  may  result  in  baldness. 

Treatment.  The  general  health,  in  the  majority  of  instances, 
requires  tonics.  Oleum  morrhua,  and  syrupus  ferri  iodidum,  are 
invaluable  to  scrofulous  patients.  Cleanliness  is  essential  to  success- 
ful management. 

For  tinea  favosa  pilaris  et  capitis  two  remedies  are  essential — 
parasiticides  and  depilation.  The  hair  should  be  cut  off  as  short  as 
possible,  the  crusts  removed  by  the  use  of  oil,  or  soap  and  hot  water, 
or  poultices,  again  well  oiled,  and  the  hairs  removed  by  means  of 
broad-bladed  forceps,  a  few  hairs  being  removed  at  a  time  and  only 
a  small  surface  cleared  at  each  sitting,  when  the  following  lotion  is  to 
be  thoroughly  applied : 

R.      Hydrarg.  chlorid.  corrosiv. ,      .    .    .     gr.  v-x  0.3-0.6  Gm. 

Ammonii  chlorid., ^^  ss  2.  Gm. 

MisturK  amygdalae  amar.,      .    .    .    .f^iv  120.  Cc.      M. 
SiG. — Apply  thoroughly.     (Bulkley.) 


DISEASES   OF  THE  SKIN.  595 

Dr.  Shoemaker  condemns  epilation  as  injurious  to  the  "  hair-folli- 
cles and  painful  to  the  patient,  and  should  be  discarded  as  a  relic  of 
medical  barbarism  of  the  last  century."  He  recommends"  the  appli- 
cation oi  oleum  ergoice,  for  twenty-four  hours,  to  soften  the  crusts ;  then 
apply  a  twenty-five  to  a  fifty  per  centum  solution  of  boroglyceridum, 
sponged  thoroughly  over  the  affected  surface  covered  with  the  oil ;  in 
a  few  hours  the  crusts  will  peel  off  and  the  surface  can  be  cleansed, 
when  the  following  powerful  antiparasitics  should  be  applied  "  : 

R.     Ung.  hydrargyrioleat.,  .    .    .    .    ,^ss  15.  Gm. 

Adeps,      ^ss  15.  Gm. 

SiG. — Apply  a  small  portion  to  each  cup  daily  for  two  or  three  days. 

Then  alternate  with  the  following  : 

R  .     Cupri  oleat. , ^:^  ss  2.  Gm. 

Adej)s, ^j  30.   Gm. 

SiG. — Small  portion  to  the  affected  spots. 

"These  applications  should  be  made  every  day  or  two,  and  con- 
tinued for  three  or  four  weeks.  If,  after  a  cessation  of  treatment  for 
a  week  or  two,  the  hair  does  not  assume  its  natural  aspect  and  new 
favus  crusts  develop,  the  treatment  should  be  begun  afresh." 


TINEA  CIRCINATA. 

Synonyms.  Tinea  trichophytina  corporis ;  herpes  circinatus  ; 
ringworm  of  the  body. 

Definition.  A  contagious,  parasitic  affection  of  the  skin,  due  to 
the  trichophyton  fungus ;  characterized  by  the  development  of  one 
or  more  circular  or  irregularly  shaped,  variously  sized,  inflammatory, 
slightly  vesicular  or  squamous  patches,  occurring  upon  the  general 
surface  of  the  body. 

Causes.  Ringworm  of  the  body  is  caused  by  the  presence  of  a 
vegetable  parasite  discovered  by  Bazin,  in  1854,  termed  the  tricho- 
phyton, the  same  growth  or  fungus  that  produces  tinea  tonsurans  and 
tinea  sycosis.  The  affection  is  highly  contagious,  and  is  frequently 
communicated  from  one  member  of  a  family  to  another,  although  it 
has  been  determined  that  a  certain  unknown  condition  of  the  skin  is 
requisite  for  its  development.  In  children  it  is  most  frequently  seen 
among  the  weakly  and  the  poorly  nourished.  In  adults  it  is  usually 
associated  with  a  decline  in  the  general  health. 


596  PRACTICE    OF    MEDICINE. 

Pathology.  The  fungus  is  seated  between  the  strata  of  the  epi- 
dermis, more  particularly  in  the  superior  layers  of  the  rete.  The 
presence  of  this  foreign  body  produces  the  subsequent  phenomena — 
a  superficial  dermatitis,  erythema,  exudation,  minute  vesiculation  and 
papulation,  and,  in  the  severe  grades,  tubercles  and  pustules.  The 
desquamative  symptoms  are  exfoliative — nature's  efforts  for  relief. 

Symptoms.  Tinea  circinata  varies  greatly  in  the  degree  of  its 
development,  from  the  trivial  complaint  so  often  seen  in  children,  to 
the  chronic,  extensive,  and  obstinate  disease  sometimes  seen  about 
the  thighs  in  adults  {tittea  circinata  cruris). 

The  disease  usually  begins  as  a  small,  reddish,  scaly,  rounded  or 
irregularly  shaped  spot  of  papules,  which  in  a  very  few  days  assumes 
a  circular  form  (ringworm).  It  continues  to  increase  in  size,  the 
papules  often  changing  to  vesicles.  A  characteristic  of  the  eruption 
is  its  healing  in  the  centre  as  it  spreads  on  the  periphery.  Occasion- 
ally the  circles  or  rings  coalesce,  forming  serpiginous  lesions.  The 
usual  size  of  a  fully  developed  ringworm  is  about  that  of  a  silver 
quarter  of  a  dollar. 

Chronic  tinea  circinata  does  not  present  the  characteristic  annular 
form,  but  "  are  usually  in  the  form  of  single  or  multiple,  disseminated, 
small,  reddish,  slightly  scaly,  ill  defined  spots,  on  a  level  with  or  but 
slightly  raised  above  the  surrounding  skin.  Not  infrequently  they 
are  the  size  of  a  small  or  large  finger-nail,  and  are  irregularly  shaped, 
and,  as  a  rule,  without  line  of  demarcation." 

The  "eczema  marginatum"  of  Hebra  is  to  be  looked  upon  as  a 
severe  form  of  tinea  circinata. 

Tinea  circinata  cruris,  or  ringworm  of  the  thighs,  a  variety  of  the 
"eczema  marginatum"  of  Hebra,  is  usually  complicated  with  true 
eczema,  and  is  a  very  obstinate,  chronic  form  of  the  affection  ;  it  is 
accompanied  by  severe  itching. 

Tinea  trichophytina  unguium  is  a  rare  variety.  The  nails  become 
opaque,  whitish,  thickened,  and  soft  and  brittle,  especially  along 
their  free  border.  The  microscope  is  essential  for  a  diagnosis.  Its 
course  is  chronic,  and  it  is  difficult  to  cure. 

Course.  As  commonly  seen,  ringworm  is  very  amenable  to  treat- 
ment. Occasionally,  however,  it  exhibits  great  obstinacy,  showing 
itself  repeatedly  in  the  same  region  in  the  form  of  relapses,  or  mani- 
festing itself  from  time  to  time  in  new  localities. 

Diagnosis.     Tinea  circinata  may  be  mistaken  for  squamous  or 


DISEASES   OF   THE  SKIN.  597 

Other  varieties  of  eczema,  but  the  circular  and  often  annular  form, 
the  well-defined  margin,  the  slight  desquamation,  and  the  course  and 
history  of  ringworm  should  prevent  error.  Chronic  ringworm  is  more 
difficult,  however. 

Seborrhoea  and  psoriasis  often  assume  a  somewhat  circular  form, 
and  then  have  a  resemblance  to  ringworm,  but  a  study  of  the  clini- 
cal history  should  render  the  diagnosis  easy. 

All  doubtful  points  in  diagnosis  should  be  determined  by  the  micro- 
scope. The  examination  can  readily  be  made  in  the  following  man- 
ner :  "  A  few  of  the  scales  may  be  scraped,  with  a  blunt  knife-blade, 
from  the  suspected  patch  and  placed  upon  a  glass  slide  containing  a 
drop  of  liquor  potassae,  over  which  is  laid  a  thin  glass  cover.  The 
cover  should  be  pressed  down  and  the  epidermic  mass  flattened  out. 
Permitting  the  specimen  to  remain  for  a  few  minutes,  it  may  be  viewed 
with  a  power  of  from  250  to  500  diameters.  The  fungus  will,  in  most 
cases,  be  detected  here  and  there,  having  at  first  a  faint  outline,  but 
becoming  more  distinct  as  the  specimen  stands." 

Prognosis.  Favorable,  as  a  rule,  although  the  affection  is  rebel- 
lious to  treatment  in  some  instances,  and  prone  to  relapses. 

Treatment,  Local  treatment  is  usually  all  that  is  required  for 
the  cure  of  tinea  circinata.  In  the  majority  of  instances  the  following 
plan  will  be  successful.  Washing  the  patch  with  soft  soap  and  water 
and  the  application  of  one  of  the  following  ointments  : 

R.      Cupri  acetat. gr.  x  0.6  Gm. 

Ung.  aquae  rosse, ^j  30.     Gm.  M. 

SiG. — Keep  in  contact  with  the  patch. 
Or— 

R.      Hydrargyri  ammoniat. ,     .    .    .    .    gr.  xx-xxx   1. 3-2.     Gm. 

Ung.  petrolei, .    ^j  30.     Gm.  M. 

SiG. — Keep  in  contact  with  the  patch. 
Or— 

R.      Hydrargyri  chloridi  cor.,      ...     gr.  j  0.065  Gm. 

Tinct.  benzoin,  comp.,     ....  f^j  30.  Cc.  M. 

SiG. — Apply  over  eruption. 

Or— 

R .     Sulphuris, 5 j  4.  Gm. 

Acid,  borici, gj  4.  Gm. 

Vaselini, g  j  30.  Gm.  M. 

SiG. — Apply  after  scrubbing  patch  with  green  soap. 


598  PRACTICE    OF    MEDICINE. 

In  obstinate  tinea  circinata  cruris  a  saturated  solution  of  acidum 
boricton,  applied  for  a  few  days,  and  afterward  cover  the  parts  with 
the  acid  in  powder,  or  unguentum  hydrargyri  ammoniatum. 


TINEA  TONSURANS. 

Synonyms.  Tinea  trichophytina  capitis  ;  herpes  tonsurans ;  ring- 
worm of  the  scalp. 

Definition.  A  contagious,  parasitic  affection  of  the  scalp,  due  to 
i\\t.  trie hophyto)i  fungus  ;  characterized  by  the  development  of  circum- 
scribed, vesicular  or  squamous,  more  or  less  bald  patches,  showing 
the  hair  to  be  diseased  and  usually  broken  off  close  to  the  scalp. 

Cause.  The  resultof  the  presence  and  growth  of  the  same  fungus 
giving  rise  to  tinea  circinata — trichophyton.  It  is  an  affection  of  child- 
hood, seldom  being  seen  after  puberty.  It  is  highly  contagious,  and 
may  be  communicated  from  a  case  of  ringworm  of  the  body. 

Pathology.  The  parasite,  originally  named  "  trichophyton  tonsu- 
rans,'' invades  the  hair,  hair-follicles,  and  epidermis  of  the  scalp,  the 
hair,  however,  suffering  the  most  severely,  becoming  in  a  short  time 
filled  with  the  growth  to  such  an  extent,  usually,  as  to  cause  its  disin- 
tegration and  destruction.  The  hair-follicle,  also,  becomes  distended 
and  prominently  raised.  The  hair-shaft  is  fractured  just  above  the 
level  of  the  scalp,  and  usually  presents  a  jagged,  bristly,  stubble-like 
extremity.  The  epidermis  of  the  scalp  may  either  present  the  changes 
of  minute  vesicles  and  desquamation,  or,  in  severe  cases,  oedema 
and  inflammatory  symptoms,  with  fluid  exudation  {tinea  ker ion'). 

Symptoms.  Ringworm  of  the  scalp  usually  begins  in  the  form 
of  small  circumscribed  patches,  which  soon  become  the  seat  of  small 
vesicles  or  pustules,  which  terminate  in  desquamation,  or  of  furfur- 
aceous  scales.  The  patches  spread  rapidly,  soon  reaching  the  size  of 
a  silver  quarter  to  that  of  a  silver  dollar.  They  are  circular  in  form, 
circumscribed,  of  a  reddish,  grayish,  or  greenish-yellow  color,  covered 
with  fine  or  coarse  scales,  with  the  hairs  broken  off  close  to  the  scalp. 
The  epidermis  of  the  scalp  is  more  or  less  raised,  and  the  follicles 
are  prominent,  giving  the  characteristic  appearance  of  the  disease — 
the  goose-skin  or  pluckedfowl  appearance.  As  a  result  of  the  loss 
of  hair,  baldness,  more  or  less  complete,  but  temporary,  exists. 

Itching,  slight  or  severe,  is  a  constant  symptom. 


DISEASES   OF  THE   SKIN.  599 

Ringworm  of  the  face  or  body  {tinea  cbcinata)  may  complicate 
tinea  tonsurans. 

Chronic  ringworm  of  the  scalp  is  the  same  condition  in  a  more 
chronic  form,  having  existed  for  six  months  to  a  year  or  two. 

Tmea  kerion  is  a  severe  variety  of  tinea  tonsurans,  "  characterized 
by  oedema,  inflammation,  and  the  exudation  of  a  viscid,  glutinous, 
yellowish  secretion  from  the  opening  of  the  hair-follicles.  When 
fully  developed  the  patches  are  yellowish,  reddish,  or  purple  in  color, 
and  are  more  or  less  raised,  oedematous,  and  boggy.  They  are  uneven 
and  honeycomb-like  (hence  the  name  kerion),  and  studded  with 
yellowish,  suppurative  points,  or,  later,  with  small  cavities  or  foramina, 
the  openings  of  the  distended  hair-follicles  deprived  of  their  hairs, 
which  discharge  a  mucoid,  gummy,  honey-like  fluid." 

The  patches  are  tender,  painful,  and  at  times  the  seat  of  itching. 
The  course  of  the  affection  is  chronic. 

Diagnosis.  The  diagnosis  is  usually  unattended  with  difficulty, 
if  the  characteristic  circumscribed  vesicular  or  scaly  patches  with 
stubby  hair  be  present. 

Squamous  eczema  somewhat  resembles  tinea  tonsurans,  but  the 
hairs  are  normal  in  eczema  and  firmly  imbedded  in  the  follicles, 
while  they  are  almost  always  stumpy  in  ringworm,  and  in  those  cases 
in  which  they  are  not  broken  off,  if  pulled,  they  easily  fall  out.  Ring- 
worm is  contagious,  eczema  is  not. 

Alopecia  areata  presents  a  white,  shiny,  ivory-like,  bald  patch,  de- 
void of  scales,  eruption,  or  hair.  Ringworm  has  the  vesicular  or  scaly 
patch,  with  broken-ofif  hairs. 

In  any  case  of  doubt  the  microscope  will  readily  determine  the 
diagnosis,  if  "  one  or  two  of  the  short,  stumpy  hairs  should  be  placed 
upon  a  slide  with  a  drop  of  liquor  potassce  and  permitted  to  stand  a 
few  minutes,  when  under  a  power  of  two  hundred  and  fifty  diameters 
the  fungus,  as  well  as  the  lesions  of  the  hair,  will  be  visible." 

Prognosis.  Favorable,  although  obstinate  in  chronic  cases.  Re- 
lapses are  of  frequent  occurrence. 

Treatment.  Local  measures  are  usually  satisfactory.  Mild  cases 
should  be  treated  by  cutting  the  hair  as  close  as  possible  and  thor- 
oughly scrubbing  the  patches  with  sapo  viridis  and  water,  or  the  ap- 
plication twice  daily  of  a  twenty-five  to  a  fifty  per  centum  solution  of 
boroglyceridum,  or  a  six  per  centum  solution  of  oleatum  hydrargyri,  or 
either  of  the  following  : 


600  PRACTICE    OK    MKDICINE. 

li .     Sodii  borat., ^]  4.  Gm. 

Aceti  destil. f  5  ij  60.  Cc.  M, 

SiG. — Apply  tboroughly  several  times  daily. 

Or— 

R .     Acidi  horici, gr-  xv  i.  Gm. 

Sulphur,  llor. , Rr.  xv  i.  Gm. 

Vaselini, 3 'ss  45.  Gm.               M 

Sir.. — Apply  morning  and  night. 

Or— 

K.     Cupri  oleat., z^s  2.  Gm. 

Ung.  petrolei, 3  i j  60.  Gm.  M, 

SiG. — Apply  after  using  boric  solution. 

Or  use  may  be  made  of  Morris'  thymol  solution,  to  wit : 

Be-     Thymol gss  2.  Gm. 

Chloroformi, f^^^ij  8.  Cc. 

01.  olivx', f  3  vj  24.  Cc.  M. 

A  preparation  very  popular  in  London,  known  as  Coster's  paste,  is 
used  by  painting  the  patches  with  a  brush  and  allowing  it  to  remain 
on  until  the  crust  is  cast  off,  in  the  course  of  five  or  six  days,  when 
it  may  be  reapplied.  A  few  applications  often  suffice.  Its  formula  is — 

R .     lodi, ,. 5  ij  8.  Gm. 

Olei  picis, f^j  30.  Cc.  M. 

The  iodine  and  oil  of  tar  should  be  gradually  and  slowly  mixed. 

An  excellent  application  in  rebellious  cases  is — 

R .     PotasscE  (caustic), gr.  ix  0.6  Gm. 

Acid,  carbolici, gr.  xxiv  1.5  Gm. 

Adeps  lana;  hydrosus,       ....     ,^ss  15.     Gm. 

01.  theolsromce, fSss  15.     Cc.  M. 

SiG. — A  small  amount  rubbed  into  head  night  and  morning.  If  the  scalp 
is  not  shaved,  the  application  is  retained  better. 

The  following  is  an  excellent  application  for  the  scalp  in  tinea  ton- 
surans and  other  scalp  diseases  : 

R.     Ung.  acid,  borici,      ^ij  60.  Gm. 

Ung.  eucalyptol, ^ij  60.  Gm. 

01.  caryophylli, f^ss  2.  Cc. 

Glycerini, .     q.  s.  q.  s.  M. 

Ft.  unguentum. 

Cases  which  resist  these  means  are  to  be  treated  by  removing  the 


DISEASES   OF  THE   SKIN.  601 

loose  hairs  about  the  edges  of  the  patches  and  the  broken-off  hairs 
over  the  surface  by  means  of  small,  broad-bladed,  short  forceps,  a 
few  hairs  only  being  seized  at  a  time,  a  portion  of  the  diseased  hairs 
to  be  removed  each  day  until  the  surface  has  been  cleared.  After 
each  depilation  one  of  the  above  formulae  to  be  applied. 


TINEA  SYCOSIS. 

Synonyms.  Tinea  trichophytina  barbae ;  sycosis  parasitica ; 
barbers'  itch  ;  ringworm  of  the  beard. 

Definition.  A  contagious,  parasitic  affection  of  the  hair,  hair- 
follicles,  and  subcutaneous  tissues  of  the  hairy  portion  of  the  face  and 
neck  in  the  adult  male,  due  to  the  trichophyton  fungus  ;  character- 
ized by  the  development  of  tubercles  and  pustules. 

Causes.  Tinea  sycosis  is  the  result  of  the  presence  and  growth  of 
the  same  vegetable  parasite  that  causes  tinea  circinata  and  tinea  ton- 
surans— trichophyton — which  invades  the  hair-follicle  and  hair.  It 
is  highly  contagious,  and  is  said  to  be  acquired,  in  most  cases,  at  the 
hands  of  the  barber  (?).  It  is  not  a  very  common  affection.  Like 
the  other  vegetable  growths,  it  seems  to  require  some  peculiar,  un- 
known condition  of  the  skin  for  its  development.  It  may  develop 
from  a  case  of  tinea  circinata  or  develop  simultaneously  with  it. 

Pathology.  The  parasite  finds  its  way  into  the  hair-follicles  and 
attacks  the  root  and  shaft  of  the  hair,  causing  inflammation,  followed 
by  more  or  less  follicular  suppuration  and  general  infiltration  of  the 
surrounding  tissues.  The  irritation  caused  by  the  presence  of  the 
fungus  results  in  inflammation  of  the  subcutaneous  connective  tissue 
and  the  well-known  tubercular  formations  peculiar  to  the  affection. 
They  are  firm,  comparatively  painless,  and  manifest  but  little  dispo- 
sition to  undergo  change,  remaining  during  the  presence  of  the  fungus 
and  finally  gradually  disappearing  without  leaving  a  scar.  Under  the 
microscope  the  parasite  is  plainly  discernible. 

Symptoms.  Barbers'  itch  begins  as  an  attack  of  tinea  circinata 
— as  one  or  more  reddish,  scaly  patches.  Soon  the  redness  and  des- 
quamation become  more  decided,  attended  with  swelling  and  indura- 
tion. The  hairs  will  also  be  dry,  brittle,  inclined  to  break,  and  many 
of  them  are  already  loose.  The  process  rapidly  increases,  the  skin 
becomes  distinctly  nodular  and  lumpy,  and  points  of  pustulation  de- 
51 


602  PRACTICE    OF    MEDICINE. 

velop  about  the  openings  of  the  hair-follicles.  The  subcutaneous  con- 
nective tissue  is  also  involved,  giving  rise  to  thick,  firm  masses  of  in- 
duration. 

The  surface  has  a  dark-red  or  purplish  color,  and  is  studded  with 
variously  sized  tubercles  and  pustules.  In  some  instances  the  num- 
ber of  tubercles  are  in  excess,  while  in  others  the  pustules  are  more 
numerous,  numbers  of  them  discharging,  and  are  succeeded  by  thick 
crusts,  which  are  often  so  abundant  as  to  simulate  pustular  eczema. 

The  hairs  are  always  diseased,  and  break  off  either  in  the  follicles 
or  just  above  the  level  of  the  surface.  Those  not  breaking  drop  out, 
leaving  the  region  partly  or  wholly  devoid  of  hair. 

The  most  frequent  location  attacked  is  the  chin,  neck,  and  sub- 
maxillary region.  One  or,  what  is  more  common,  both  sides  of  the 
face  are  involved. 

I/L/iing,  burning,  pain,  and  swelling  always  accompany  the  affec- 
tion, varying  in  intensity  from  moderate  to  very  severe. 

The  course  of  the  affection  is  usually  chronic.  Relapses  are  fre- 
quent, unless  most  thoroughly  eradicated. 

Diagnosis.  Sycosis  non-parasiiica  occasions  difficulty  of  diag- 
nosis at  times.  The  points  of  difference,  however,  are  usually  so 
marked  that  error  should  not  occur. 

Sycosis  non-parasitica  is  a  chronic,  inflammatory,  non-coniagious 
affection  of  the  hair-follicles,  characterized  by  the  development  of 
papules  and  pustules  which  are  perforated  with  hairs,  the  hairs  them- 
selves being  unaffected.  The  upper  lip,  cheeks,  and  chin  are  the 
parts  mostly  involved.  If  of  long  duration,  some  inflammatory 
thickening  results. 

In  tinea  sycosis,  or  sycosis  parasitica,  the  skin  and  subcutaneous 
connective  tissue  are  extensively  involved,  as  manifested  by  the  in- 
duration and  formation  of  the  characteristic  tubercles.  The  upper 
lip  is  rarely  invaded  ;  the  hairs  are  diseased,  broken  off,  or  loose,  and 
under  the  microscope  reveal  the  parasite. 

Pustular  eczema  resembles  tinea  sycosis,  with  extensive  pustulation 
and  crusting;  but  in  the  former  the  hairs  are  not  involved,  nor  aie 
the  characteristic  tubercles  present. 

Treatment.  Local  measures  are  sufficient  for  the  cure  of  tinea 
sycosis.  In  the  majority  of  instances  the  following  procedure  will 
effect  a  cure  in  three  or  four  weeks.  If  crusts  are  present, — and  almost 
always  some  are, — they  are  to  be  thoroughly  saturated  with  inunctions 


DISEASES   OF   THE   SKIN.  603 

of  almond  or  olive  oil,  and  removed  by  washing  with  soft  soap  and 
water.  The  part  is  then  cleanly  shaved,  the  first  operation  being 
more  painful  than  subsequent  ones.  After  shaving,  the  affected  sur- 
face is  bathed  for  ten  minutes  in  water  as  hot  as  can  be  borne. 
All  pustules  are  then  opened  with  a  fine  needle,  and  the  parts 
sponged  freely  for  several  minutes  with  a  solution  of  sodii  hypo- 
sulphitis,  Z]  (4  Gm.) ;  aquce,  f^j  (30  Cc.) ;  after  which  the  parts  are 
again  thoroughly  washed  with  hot  water,  carefully  dried,  and  smeared 
with  an  unguetitum sulphuris ,  containing  3j-ij  (4-8  Gm.)  to  the  ounce. 
This  procedure  is  preferably  performed  at  night.  The  following 
morning  the  ointment  is  washed  off  with  soap  and  water,  the  face 
bathed  with  the  sodium  solution,  and  dusted  with  any  inert  powder. 
This  plan  continued  faithfully  every  night,  omitting  the  shaving  when 
the  beard  has  not  grown  much,  will  usually  be  followed  with  success. 

Cases  resisting  the  above  means  should,  in  addition,  have  the 
hairs  depilated,  the  shaving  performed  every  two  or  three  days, 
thus  allowing  time  for  the  hairs  to  grow  sufficiently  to  depilate, 
the  operation  seldom  being  as  painful  as  one  would  suppose.  Shaving 
and  depilation  upon  alternate  days  should  be  faithfully  practised 
until  the  new  hairs  are  healthy. 

In  addition  to  the  parasiticides  mentioned,  any  of  those  recom- 
mended for  the  other  vegetable  parasitic  diseases  may  be  used. 


TINEA  VERSICOLOR. 

Synonyms.     Pityriasis  versicolor  ;  liver-spots. 

Definition.  A  contagious,  parasitic  affection  of  the  skin,  due  to 
the  microsporon  furfur  ;  characterized  by  the  occurrence  of  variously 
sized,  irregularly  shaped,  dry,  slightly  furfuraceous,  yellowish  spots 
upon  the  chest  or  other  portions  of  the  body. 

Cause.  Pityriasis  versicolor  is  the  result  of  the  presence  upon  the 
surface  of  the  skin  of  a  vegetable  fungus  termed  microsporon  furfur. 
It  is  a  mildly  contagious  affection  seen  after  puberty.  It  is  said  to 
occur  most  frequently  in  those  suffering  from  wasting  diseases,  partic- 
ularly phthisis  pulmonalis.  It  is  not  connected  with  any  affection  of 
the  liver,  as  supposed  by  the  laity. 

Pathology.  The  fungus  permeates  the  horny  layer  of  the 
epidermis,  never  the  hairs  or  nails,  and  gives  rise  to  the  irregular- 


604  PRACTICE    OF    MKDICINE. 

shaped  and  sized  macula;,  of  a  yellowish  or  brownish  color.  As  a 
rule,  it  gives  rise  to  neither  hyperaeniia  nor  inflammatory  symptoms. 

Symptoms.  Tinea  versicolor  occurs  in  the  form  of  irregular, 
roundish,  circumscribed,  or  reticulated  macula:.  The  spots  vary  in 
size  from  that  of  a  small  silver  coin  to  that  of  the  hand.  By  coa- 
lescing they  often  cover  a  greater  portion  of  the  chest,  their  most 
usual  site.  Upon  close  inspection  the  surface  of  the  macule  is  seen  to 
be  covered  with  furfuraceous  scales,  and,  if  the  scales  be  not  visible, 
scraping  with  the  finger-nail  will  demonstrate  their  presence.  In 
color  the  spots  vary  from  a  delicate  buff  or  fawn  shade  to  a  yellowish, 
deep  brown,  and,  rarely,  even  blackish  hue.  At  times  mild  itching 
accompanies  the  eruption. 

Diagnosis.  The  character  of  the  eruption  is  so  distinct  that 
errors  in  diagnosis  can  hardly  occur.  If  any  doubt  exist,  a  few 
of  the  scales  upon  a  glass  slide,  with  a  drop  of  liquor  poiassce,  and 
covered  with  a  thin  glass  cover  and  placed  under  a  microscope 
with  a  power  of  from  two  hundred  and  fifty  to  five  hundred  diameters 
will  readily  determine  the  presence  of  the  fungus. 

Prognosis,     Favorable. 

Treatment.  Mild  galvanism  over  the  discolorations  is  valuable. 
The  parts  should  be  cleansed  with  soap  and  water  and  either  of  the 
following  lotions  applied  : 

R.     Sodii  sulphitis, ^iij  12.  Gm. 

Glycerin!, f_5ij  8.  Cc. 

Aqune,      ad   f^iv  ad    I20.  Cc.  M. 

SiG. — Apply  frequently. 
Or— 

K.      Hydrargyri  chlorid.  corrosiv.,      .    gr.  iv  o.  26Gm. 

Alcoholis, f^vj  24.       Cc. 

Aramonii  chlorid., _:^ss  2.       Gm. 

Aquae  rosse, ad   fjvj  ad     180.       Cc.  M. 

SiG. — Apply  frequently.     (Tilbury  Fox.) 

SCABIES. 

Synonym.    The  itch. 

Definition.  A  contagious,  animal  parasitic  disease  of  the  skin, 
due  to  the  acarus,  or  sarcopies  scabiei ;  characterized  by  the  formation 
of  cuniculi  (burrows),  papules,  vesicles,  and  pustules;  followed  by 
excoriations,  crusts,  and  general  cutaneous  inflammation,  and  accom- 
panied by  itching. 


DISEASES   OF  THE   SKIN.  605 

Cause,  Contagion.  The  only  cause  is  the  presence  of  the  ani- 
mal parasite,  the  acarus,  or  sarcoptes  scabiei.  The  affection  occurs  at 
all  ages  and  in  every  walk  of  life. 

Pathology.  Scabies  is  an  inflammation  of  the  skin  with  the 
development  of  papules,  vesicles,  pustules,  excoriations,  and  subse- 
quent crusting,  the  result  of  the  ravages  of  the  animal  parasite, 
together  with  the  irritation  produced  by  the  scratching  of  the  patient. 

The  parasite  acarus,  or  sarcoptes  scabiei,  is  a  minute  creature, 
barely  visible  to  the  naked  eye  as  a  yellowish-white,  rounded  body. 
The  female  is  the  most  commonly  met  with  ;  the  males  are  said  to 
take  no  part  in  causing  the  affection,  and  so  are  rarely  seen.  They 
are  said  to  die  in  about  a  week  after  copidation  with  the  female.  The 
female  finds  her  way  by  boring  through  the  horny  layer  into  the 
mucous  layer  of  the  epidermis,  and,  being  impregnated,  begins  at 
once  laying  her  eggs  and  at  the  same  time  making  her  burrow. 
A  variable  number  of  eggs  are  deposited,  usually  about  a  dozen,  after 
which  she  perishes  in  the  skin.  The  ova  hatch  out  in  six  or  ten 
days. 

Symptoms.  Scabies  is  an  artificial  dermatitis  or  eczema,  accord- 
ing to  the  amount  of  irritation  produced  by  the  presence  of  the 
parasite  and  the  traumatism  resulting  from  the  severe  scratching  of 
the  patient. 

Immediately  upon  the  arrival  of  the  itch  mite  upon  the  skin  it  begins 
its  work  of  burrowing,  and  very  soon  a  burrow,  or  cuniculus,  is  formed, 
in  which  the  eggs  are  deposited,  and  which  also  becomes  the  habitat 
of  the. female  during  the  remainder  of  her  life.  The  ova  are  hatched 
in  about  one  week  after  their  deposit,  and  at  once  begin  to  care 
for  themselves  and  to  burrow,  resulting  in  the  formation  of  as  many 
additional  cuniculi  as  there  are  active  female  mites.  It  is  the  presence 
of  these  burrowing  parasites  that  constitutes  the  irritation  resulting  in 
the  inflammation  of  the  skin,  characterized  by  the  formation  of  minute 
papules,  vesicles,  z-nd  pustules,  with  more  or  less  inflammatory  indura- 
tion. Add  to  these  the  excoriations,  scratch  marks,  fissures,  torn 
vesicles,  and  pustules  with  yellow  and  bloody  crusts,  caused  by  the 
scratching,  and  a  picture  of  the  fully  developed  disease  is  seen. 

The  burrow,  or  cimiculus,  as  it  is  termed,  is  formed  by  the  mite 
entering  and  making  its  way  beneath  the  horny  layer  of  the  epidermis, 
which  is  raised,  very  much  as  a  mole  undermines  the  ground.  It 
occurs  as  a  slight  linear  elevation  of  the  epidermis,  varying  from  a 


606  PRACTICE    OF    MEDICINE. 

half  a  line  to  four  or  five  lines  in  length,  and  having  an  irregular  or 
tortuous  course.  Its  color  is  whitish  or  yellowish,  speckled  here  and 
there  with  dark  dots.  At  either  end  the  cuniculus  terminates  as 
darkish  points,  the  more  prominent  of  which  represent  the  parasite. 

The  papules  are  the  first  inflammatory  lesion,  are  numerous  and 
of  small  size,  and  may  be  the  e.\tent  of  the  disease. 

The  vesicles  are  the  next  stage,  varying  in  size  and  number,  having 
an  inflamed  base,  sometimes  presenting  cuniculi  upon  their  summits. 

The  pustules  represent  the  completion  of  the  inflammatory  action, 
their  size  and  number  varying  with  ^he  severity  of  the  irritation. 

The  intense  itching,  which  is  worse  at  night,  results  in  excoriations, 
torn  papules,  vesicles,  and  pustules,  followed  by  crustings,  which 
after  a  time  disguise  the  characteristic  lesions.  The  regions  of  the 
body  attacked  are  the  hands,  especially  the  sides  of  the  fingers  and 
the  folds  where  they  join  the  hands.  After  a  time  the  wrists,  penis, 
and  mammae,  and  around  about  and  upon  the  nipples,  are  invaded. 

Persons  predisposed  to  eczema  have  this  affection  developed,  in 
addition  to  the  simple  dermatitis,  by  the  ravages  of  the  itch  mite. 

Diagnosis.  A  case  of  scabies  seen  before  irritated  by  scratching 
presents  no  difficulty  in  diagnosis.  The  presence  of  the  burrows 
always  suffices  for  the  diagnosis,  but  these  are  not  always  discover- 
able. The  location  of  the  eruption  always  points  strongly  to  scabies. 
A  history  of  contagion  is  of  value.  All  doubt  can  be  set  at  rest  by 
the  aid  of  the  microscope. 

Prognosis.  Always  favorable,  relapses  only  occurring  when  the 
treatment  has  been  imperfectly  carried  out  or  when  the  individual 
has  recontracted  the  disease. 

Treatment.  Local  measures  are  alone  required  in  the  treatment 
of  scabies.  The  strength  of  the  parasiticides  must  be  controlled  by 
the  severity  of  the  inflammatory  symptoms  present.  If  eczema  com- 
plicate scabies,  it  is  to  be  treated  as  an  ordinary  attack  after  the  death 
of  the  itch  mites. 

Scabies  always  succumbs  to  the  following  plan  :  The  patient  is  to 
be  thoroughly  washed  with  soft  soap  and  water,  followed  by  a  warm 
bath,  after  which  cover  eruption  with  tinctura  benzoini,  which  imme- 
diately modifies  the  itching,  or  one  of  the  following  ointments  is  to  be 
thoroughly  rubbed  into  every  portion  of  the  body,  especial  attention 
being  devoted  to  the  hands,  fingers,  and  other  parts  usually  the 
seat  of  the  disease  : 


DISEASES   OF  THE  SKIN.  60f 

R .     Styracis  liquidis, f  3  ij  8.  Cc. 

Ung.  sulphuris, 3  ij-iv  8.-16.  Gm. 

Ung.  petrolei, ad   ^'}         ad  30.  Gm.             M. 

SiG. — Apply  after  washing.      (Bulkley.) 

Or— 

R.     Sulphuris  sublimat., 3J  4.  Gm. 

Balsam  Peruviani, g^s  2.  Gm. 

Adeps, §j  30.  Gm.               M. 

SiG. — For  children.      (Duhring.) 

Or— 

R.     Creolini, .   gr.  x  0.6  Cc. 

Ung.  petrolei, ^ij  60.     Gm.  M. 

SiG. — Apply  thoroughly. 


PEDICULOSIS. 

Synonyms.     Phthiriasis  ;  morbus  pedicularis  ;  lousiness. 

Definition.  A  contagious,  animal  parasitic  disease  of  the  head, 
body,  or  pubes,  due  to  the  presence  of  pediculi  and  characterized  by 
the  wounds  inflicted  by  the  parasite,  together  with  excoriations  and 
scratch  marks. 

"Varieties.  Pediculosis  capitis  ;  pediculosis  corporis  ;  pediculosis 
pubis. 

Cause.  The  cause  is  the  presence  of  the  parasite,  the  result  of 
contagion,  direct  or  indirect.  The  view  of  "  a  spontaneous  genera- 
tion "  of  pediculi  is  not  accepted  by  the  great  majority  of  observers. 

Pathology.  The  lesion  produced  by  the  presence  of  the  pediculi 
is  a  minute  hemorrhage,  caused  by  the  parasite  inserting  its  sucking 
apparatus,  or,  as  it  is  termed,  its  haustellum,  into  a  follicle,  and  obtain- 
ing blood  by  a  process  of  sucking,  and  not  by  biting,  as  is  generally 
supposed.  The  presence  of  the  parasite  in  any  great  numbers  brings 
about  a  peculiar  irritable  state  of  the  skin,  which  gives  rise  to  an  irre- 
sistible desire  to  scratch,  as  a  consequence  of  which  the  surface  is 
markedly  excoriated  and  lacerated. 

Symptoms.  The  symptoms  which  arise  from  the  presence  of  the 
parasite  in  different  localities  are  somewhat  different,  and  call  for 
separate  consideration. 

Pediculosis  capitis.  This  variety  is  caused  by  the  presence  of  the 
pediculus  capitis,  or  head  louse.     The  ova,  or  nits,  are  readily  recog- 


608  PRACTICE   OF    MEDICINE. 

nized  at  a  distance.  Their  favorite  seat  is  the  occipital  region,  either 
upon  the  surface  of  the  scalp  or  upon  the  hair.  Their  presence  gives 
rise  to  considerable  irritation,  itching,  and  consequent  scratching,  re- 
sulting in  the  wounding  of  the  scalp,  with  oozing  of  a  serous  or  puru- 
lent fluid  mixed  with  blood,  which  soon  mats  the  hair  and  forms  into 
crusts.  In  those  predisposed  to  eczema  the  presence  of  the  parasite 
will  give  rise  to  that  condition. 

The  general  health  is  usually  unaffected  by  the  presence  of  the 
pediculi. 

Pediculosis  corporis.  This  variety  of  the  pediculosis  is  caused  by  the 
presence  of  the  pediculus  corporis,  or  body  louse,  or  more  properly 
termed  the  pediculus  vestimenti,  or  clothes  louse.  Its  color,  when 
devoid  of  blood,  is  dirty-white  or  grayish,  with  a  dark  line  around  the 
margin  of  its  abdomen.  Its  habitat  is  the  clothing  covering  the 
general  surface,  remaining  upon  the  skin  only  long  enough  to  obtain 
sustenance.  The  ova  are  usually  deposited  in  the  seams  of  the  cloth- 
ing, the  lice  being  hatched  within  the  week.  Occasionally  a  few  of 
the  pediculi  may  be  observed  crawling  about  the  surface,  or  in  the 
act  of  drawing  blood.  As  they  move  over  the  surface  they  give  rise 
to  an  intensely  disagreeable  itching  sensation,  to  relieve  which  the 
patient  scratches,  which  in  turn  gives  rise  to  the  characteristic  lesions 
of  the  affection. 

The  lesions  are  numerous.  The  scratch  marks  are  scattered  here 
and  there,  either  long  and  streaked,  in  other  places  short  and  jagged, 
the  excoriations  and  blood-crusts  varying  in  size  from  a  pin-head  to  a 
split  pea  or  even  larger,  with  irregular-shaped  pustules.  In  addition 
to  the  lesions  resulting  from  the  scratching  are  seen  the  primary 
lesions,  consisting  of  minute,  reddish  puncta  with  slight  areolae,  the 
points  at  which  the  parasite  has  drawn  blood.  In  cases  of  long  stand- 
ing a  brownish  pigmentation  of  the  whole  skin  may  result  from  the 
long-continued  irritation  and  scratching.  The  favorite  site  of  the 
lesions  are  the  back,  especially  about  the  scapular  region,  the  chest, 
abdomen,  hips,  and  thighs. 

Pediculosis  is  seen  most  commonly  among  the  poorer  classes,  and 
especially  the  middle-aged  and  elderly. 

Pediculosis  pubis.  This  variety  of  pediculosis  is  caused  by  the  pres- 
ence of  the  pediculus  pubis,  or  crab  louse.  Although  having  its  seat 
of  predilection  about  the  pubes,  it  may  also  infest  the  axillae,  sternal 
region  in  the  male,  beard,  eyebrows,  and  even  eyelashes. 


DISEASES   OF  THE  SKIN.  609 

They  may  be  found  crawling  about  the  hairs,  but  more  commonly 
hugging  the  surface  closely.  They  infest  adults  chiefly,  and  occasion 
symptoms  similar  to  those  described  in  connection  with  other  species. 
They  are  usually  contracted  through  sexual  intercourse,  although 
occasionally  they  are  present  in  cases  in  which  they  have  not  been 
communicated  in  this  way,  and  where  no  explanation  as  to  the  mode 
of  contagion  can  be  suggested.  The  itching  varies  from  slight  to 
severe. 

Diagnosis.  When  violent  itching  exists  in  any  case,  without 
marked  eruption,  the  possibility  of  the  presence  of  pediculi  should 
always  be  entertained,  and  if  carefully  sought  after,  are  found. 

Prognosis.     Favorable,  if  the  treatment  be  thoroughly  carried  out. 

Treatment.  Local  measures  alone  are  all  that  is  necessary  for 
the  removal  of  the  various  forms  of  pediculosis. 

Pediculosis  capitis.  The  most  effective  application  to  this  variety 
is  to  thoroughly  soak  the  head  two  or  three  times  a  day  with  ordinary 
petroletnn  or  kerosene  oil,  and  keep  it  wrapped  in  a  cloth  for  twenty- 
four  hours.  At  the  end  of  this  time  the  head  should  be  thoroughly 
washed  with  soft  soap  and  hot  water,  dried,  and  saturated  with  the 
official  unguentuin  hydrargyri  afmnoniatum.  If  required,  this  entire 
procedure  may  be  repeated,  but  usually  any  pediculi  escaping  the 
petroleum  are  destroyed  by  the  unguentum. 

Pediculosis  corporis.  In  this  variety  the  habitat  of  the  parasite 
being  the  clothing,  they  must  be  boiled  or  baked  at  a  temperature 
sufficiently  high  to  destroy  their  life.  After  this  the  clothing  should 
be  changed  every  day  or  two,  carefully  inspected,  and  if  pediculi  are 
seen,  they  must  again  be  baked  or  boiled.  It  is  folly  to  expect  satis- 
factory results  unless  these  directions  are  faithfully  adhered  to.  For 
the  irritation,  itching,  and  excoriations,  mild  alkaline  baths  or  lotions 
of  acidum  carbolicum  are  sufficient. 

Pediculosis  pubis.  The  parts  should  be  washed  twice  daily  with 
soft  soap  and  water,  after  which  the  thorough  application  of  tinctura 
cocculus  indicus,  full  strength  or  diluted,  or  a  lotion  of  hydrargyri 
chloridujn  corrosivum  or  unguentutn  hydrargyri  ammoniatuin  or 
unguentum  hydrargyri  (blue  ointment),  will  be  -effectual. 


39 


INDEX. 


Abdominal  dropsy,  141 

typhus,  22 
Abscess,  cerebral,  424 

iliac,  129 

of  the  heart,  383 

of  the  liver,  153 

peritypblitic,  129 
Acne,  574 

artificialis,  575 

disseminata,  574 

indurata,  574 

papulosa,  574 

punctata,  534,  574 

pustulosa,  574 

rosacea,  576 

sebacea,  531 

tubercula,  574 

vulgaris,  574 
Acute  articular  rheumatism,  219 

Bright's  disease,  168 

diarrhoea,  109 

gastric  catarrh,  76 

general  diseases,  209 

hepatitis,  153 

meningitis,  404 

nasal  catarrh,  263 

toxic  gastritis,   78 

ursemia,  183 

yellow  atrophy,  154 
Addison's  disease,  203,  584 
Agraphia,  429 

amnesic,  429 
Ague,  39 

brow,  39 

cake,  39 

dumb,  39 
Albumin,  tests  for,  161 

nitric-magnesian  test,  161 


611 


Albuminuria,  169 

chronic,  1 71 
Alcoholism,  436 

acute,  436 

chronic,  443 
Amygdalitis,  272 
Amyloid  kidney,  180 
Ansematosis,  199 
Anemia,   195 

Blaud's  pill  for,  198 

cerebral,  414 

England's  pill  for,  198 

essential,  197 

lymphatic,  202 

of  fatty  heart,  199 

progressive  pernicious,  199 

splenica,  201 
Anatomy,  morbid,  II 
Aneurism  of  the  abdominal  aorta,  4  "xa 

of  the  arch  of  aorta,  399 

of  the  thoracic  aorta,  399 
Angina  catarrhalis,  269 

pectoris,  393 
Anidrosis,  540 
Anthrax,  571 

Aorta,  aneurism  of  the,  398 
Aphasia,  429 
Aphonia,  429 
Aphtha,  69 

confluens,  69 

discrete,  69 
Aphthous  stomatitis,  69 
Apnoea,  14 
Apoplexy,  415 

capsular,  417 

cortical,  417 
crus-cerebri,  417 
ingravescent,  416 


612 


INDEX. 


Apoplexy,  serous,  446 

Ajipendicitis,  129 

Argyria,  5S4 

Arrhythmia,  393 

Arteries,  Cohnheim's  terminal,  42I 

Arteriocapillary  fibrosis,  396 

Arterio-sclerosis,  396 

Arthritis  deformans,  227 

Artisans'  cramp,  500 

Ascaris  lumbncoides,  137 

Ascites,  144 

Asthenia,  14 

Asthma,  302 

bronchial,  302 

hay,  306 

Kopp's,  286 

Millar's,  286 

spasmodic,  302 

thymic,  286 
Ataxia,  locomotor,  467 
Ataxic  paraplegia,  470 
Atheroma,  396 

iodides  in,  398 
Atonic  dyspepsia,  96 
Atrophic  paralysis  of  children,  458 
Atrophy,  chronic  spinal  muscular,  462 

progressive  muscular,  462 
Atropia  for  hemorrhage,  315 
Auscultation,  252 

Da  Costa's  rules  for,  252 
Autumnal  catarrh,  306 

fever,  22 

Bacillus,  comma,  239 

malaria,  39 

of  Eberth,  23 

of  PfeilTer,  19 

tuberculosis,  332 
Bacteria  of  decomposition,  239 
Bacteriology,  11 
Barbers  itch,  601 
Basedow's  disease,  495 
Basham's  iron  mixture,  171 
Bell's  palsy.  483 
Belt,  hydropathic,  152 
Beriberi,  476 
Bile,  test  for,  147 

pigment,  test  for,  I47 
Biliary  calculi,  149 
Bilious  cholera,  113 

fever,  42,  71 


Bilious  malignant  fever,  48 

remittent  fever,  42 
Biliousness,  151 
Black-heads,  534 
Bladder,  catarrh  of,  1 90 
Blaud's  pill,  198 
Bleeders'  disease,  204 
Blepharospasm,  484 
Blood,  diseases  of,  195 

test  for,  163 

white  cell,  20I 
Bloody  flux,  121 
Boil,  569 

Bothriocephalus  latus,  134 
Bowels,  inflammation  of,  I09 
Brachycardia,  392 
Bradycardia,  392 
Brain,  congestion  of,  4 12 
Brand's  method,  30 
Break-bone  fever,  67 
Bright's  disease,  acute,  168 

chronic,  171,  175,  180 
Bromidrosis,  537 

pedum,  537 
Bronchial  catarrh,  290 

dilatation,  299 

hemorrhage,  313 
Bronchiectasis,  298 
Bronchitis,  acute,  290 

capillary,  293,  328 

chronic,  298 

croupous,  296 

diphtheritic,  296 

fetid,  298 

fibrinous,  296 

membranous,  296 

peri-,  303 

plastic,  296 

secondary,  298 

senile,  298 
Broncho-pneumonia,  293,  328 
Bronchorrhagia,  313 
Bronchorrhoea,  298 
Bronzed-skin  disease,  203 
Brow  ague,  41 

Cy^CUM,  inflammation  of,  127 
Calculi,  alternating,  188 

biliary,  149 

cutaneous,  535 

hepatic,  149 


613 


Calculi,  oxalate  of  lime,  1 88 

phosphatic,   1 88 

renal,  187 

uric  acid,  188 
Callositas,  586 
Cancer,  gastric,  87 

hepatic,  158 
Cancrum  oris,  75 
Carbolic  acid  in  tetanus,  499 
Cart'uncle,  571 
Carbunculus,  57 1 
Carcinoma,  gastric,  87 

of  the  liver,  158 
Cardiac  dilatation,  380 

fatty  degeneration,  387 

hypertrophy,  377 

paralysis,  213 

valvular  diseases,  369 
Cardialgia,  94 
Carditis,  383 

chronic,  384 
Catalepsy,  492 

Catarrh,  acute  bronchial,  290 
gastric,  76 
nasal,  263 

autumnal,  306 

chronic  bronchial,  298 
gastric,  81 
nasal,  267 

contagious,  19 

dry,  298 

intestinal,  109 

mucous,  298 

of  the  bile-ducts,  147 

of  the  bladder,  1 90 

of  the  mouth,  68 

of  the  rectum,  13I 

suffocative,  293 
Catarrhal  enteritis,  109 

jaundice,  147 

laryngitis,  274 

nephritis,  167 

pneumonia,  328 

stomatitis,  68 

tonsillitis,  269 
"  Catarrh  sec  "  of  Laennec,  299 
Cephalic  tetanus,  498 
Cephalodynia,  224 
Cerebral  abscess,  424 

ansemia,  414 

congestion,  412 


Cerebral  embolism,  421 

fever,  464 

hemorrhage,  415 

hyperemia,  412 

softening,  416 

thrombosis,  421 

tumors,  426 
Cerebro-spinal  fever,  35 

neuroses,  484 

sclerosis,  471 
Cervico-brachial  neuralgia,  480 
Cervico-occipital  neuralgia,  480 
Cheyne-Stokes  breathing,  388 
Chicken-pox,  63 
Child-crowing,  279 
Chills  and  fever,  39 
Chiragra,  229 
Chloasma,  583 

uterinum,  584 
Chlorides,  test  for,  161 
Chlorosis,  197 
Cholera,  239 

Asiatic,  239 

bilious,  113 

English,  113 

epidemic,  239 

infantum,  119 

malignant.  239 

morbus,  113 

spasmodic,  239 

sporadic,  1 13 

typhoid,  239 
Cholerine,  240 
Chorea,  484 

Huntington's,  485 

post-hemiplegic,  485 
Chromidrosis,  537 
Chronic  dyspepsia,  81 

entero-colitis,  116 

gastric  catarrh,  81 

gastritis,  81 

nasal  catarrh,  267 

valvular  disease,  369 
Circular  insanity,  514 
Clavus,  587 
Clinical  history,  12 
Cohnheim's  terminal  arteries,  421 
Cold  in  the  head,  263 
Colic,  hepatic,  149 

intestinal,  102 

lead,  103 


614 


INDEX. 


Colic,  ovarian,  103 

renal,  1S7 

stomachic,  04 

uterine,  I03 
Colitis,  121 

ulcerative,  121 
Coma,  14 

urainic,  183 
Comedo,  534 
Comedones,  534 
Congestion,  cerel)ral,  412 

of  the  kidneys,  167 

of  the  liver,  151 

of  the  lungs,  316 

spinal,  449 
Congestive  fever,  44 
Constipation,  104 
Consumption,  pulmonary,  332 

galloping,  332 

throat,  288 
Contagious  fever,  ^;^ 

catarrh,   19 
Convulsions,  un\mic,  183 
Cor  bovinum,  371 
Corns.  587 
Corrigan's  disease,  340 

hammer,  442 

sign,  89 
Coryza,  acute,  263 

chronic,  267 
Costiveness,  104 
Cough,  whooping,  308 

winter,  298 
Cow-pox,  63 
Crisis,  13 
Croup,  catarrhal,  279 

false,  279 

membranous,  281 

pseudo-,  286 

spasmodic,  279 

true,  281 
Croupous  bronchitis,  296 

enteritis,  112 

laryngitis,  281 

pneumonia,  319 

stomatitis,  69 
Cyst,  renal,  182 

sebaceous,  536 
Cysticercus  bovis,  135 

cellulosus,  134 
Cystitis,  190 


Cystitis,  acute,  190 
chronic,  190 

Dandruff,  531 
Dandy  fever,  67 
Death,  14 

Delirium  tremens,  438 
Delusional  insanity,  516 
Dementia,  527 

acute,  528 

alcoholic,  529 

apo|ilectica,  529 

choreica,  529 

ciironic  529 

epileptic,  513,529 

organic,  529 

parnlytica,  529 

paretic,  521 

partial,  530 

primary,  530 

secondary,  530 

senilis,  530 

syphilitica,  530 

toxica,  530 
Dengue,  67 
Diabetes  insipidus,  236 

meliitus,  232 
Diagnosis,  14 

by  exclusion,  I4 

differential,  I4 

direct,  14 

physical,   244 
Diarrhcea,  106 

acute,  106,  109 

bilious,  106 

choleriform,  1 19 

chronic,  106 

feculent,  106 

inflammatory,  II5 

lienteric,  106 

mixture,  Squibb's,  108 
Diathesis,  12 
Dilatation,  bronchial,  299 

cardiac,  380 

gastric,  90 
Diphtheria,  210 

bronchial,  296 

laryngeal,  213,  281 

nasal,  213 
Diphtheritic  paralysis,  213 

stomatitis,  70 


INDEX. 


615 


Dipsomania,  439 

Discharges,  chopped  spinach,  n6 

rice  water,  no,  1 14 
Disease,  9 

acute,  13 

Addison's,  203,  584 

Basedow's,  495 

bleeders',  204 

Bright's,  168,  171,  175,  180 

causes  of,  II 

chronic,  13 

Corrigan's,  340 

defined,  9 

Duchenne's,  465 

fish-skin,  590 

flesh-worm,  138 

Fothergill's,  479 

functional,  9 

Graves',  495 

Hodgkin's,  202 

Meniere's,  43 1 

organic,  9 

Parkinson's,  501 

predisposition  to,  12 

subacute,  13 

termination  of,  1 3 
Diseases,  acute,  general,  209 

general  or  nutritional,  484 

mental,  504 

of  the  biliary  passages,  I47 

of  the  blood,  1 95 

of  the  bronchial  tubes,  290 

of  the  cerebral  membranes,  402 

of  the  cerebrum,  409 

of  the  circulatory  system,  352 

of  the  intestinal  canal,  99 

of  the  kidneys,  159 

of  the  larynx,  274 

of  the  liver,  151 

of  the  lungs,  316 

of  the  mouth,  68 

of  the  nasal  passages,  263 

of  the  nerves,  475 

of  the  nervous  system,  401 

of  the  peritoneum,  140 

of  the  pharynx,  269 

of  the  pleura,  346 

of  the  respiratory  system,  244 

of  the  skin,  531 

of  the  spinal  cord,  449 

of  the  stomach,  76 


Disorders  of  secretion,  531 
Dizziness,  431 
Dobell's  solution,  54 
Dropsy,  cutaneous,  52 

of  the  abdomen,  141 

of  the  pleura,  350 

pericardial,  364 

peritoneal,  141 

pleural,  350 
Duchenne's  disease,  465 
Duodenitis,  109 
Dysentery,  acute,  121 

chronic,  124 

croupous,  121 

epidemic,  122 

nuclein  in,  126 

sporadic,  122 

washing  rectum  in,  126 
Dyspepsia,  96 

acid,  97 

atonic,  96 

chronic,  81 

drunkards',  8 1 

flatulent,  97 

hot  water  in,  78 

intestinal,  99 

irritative,  97 

nervous,  97 

Ecstasy,  492 
Ecthyma,  568 
Eczema,  542 

acute,  543 

ani,  555 

aurium,  554 

barbae,  553 

capitis,  551 

chronic,  545 

erythematosum,  543 

faciei,  552 

fissum,  545 

genitalium,  554 

impetiginosum,  544 

intertrigo,  555 

labiorum,  552 

madidans,  544 

mammarum,  556 

palmarum,  55^ 

palpebrarum,  553 

papillomatosum,  545 

papulosum,  543 


r.io 


Eczema  plantaruni,  556 

pustulosum,  544 

rimosum,  545 

rubrum,  544,  549 

sclerosum,  545 

squamosum,  545 

unguium,  557 

verrucosum,  545 

vesiculosum,  544 
Elixir,  triple,  389 
Embolism,  cerebral,  421 
Emphysema,  310 
Empyema,  347 
Encephalitis,  acute,  424 

suppurative,  424 
Endarteritis  chronica  deformans,  396 
Endocarditis,  acute,  364 

chronic,  369 

diphtheritic,  365 

malignant,  367 

mycotic,  367 

septic,  367 

ulcerative,  367 
Enteralgia,  102 
Enteric  fever,  22 
Enteritis,  catarrhal,  109 

croupous,  112 

membranous,  112 
Entero-colitis,  115 
Entero-mesenteric  fever,  22 
Enteroptosis,  92 
Enterorrhcea,  I06 
Ephemeral  fever,  17 
Epidemic  catarrhal  fever,  19 

cerebru-spinal  fever,  35 

roseola,  58 
Epilepsy,  486 

Jacksonian,  4S6 
Epileptic  dementia,  513 

imbecility,  513 

insanity,  513 
Erysipelas,  64 

ambulans,  65 

of  the  brain,  65 

phlegmonous,  65 
Erysipelatous  dermatitis,  64 
Erythema  intertrigo,  541 

simplex,  540 
Erythematous  stomatitis,  68 
Erythromelalgia,  48 1 
Essential  anaemia,  199 


Etiology,  II 

Eucalyptol  in  cystitis,  193 
Exophthalmic  goitre,  495 
Exudative  endocarditis,  364 

Facial  paralysis,  483 
Farcy,  218 
I'atty  heart,  387 
Favus,  593 
Febricula,  1 7 
Fever,  15 

abdominal  typhus,  22 

autumnal,  22 

bilious,  42,  76 

remittent,  42 
typhoid,  38 

breakbone,  67 

catarrhal,  19 

cause  of,  15 

cerebral,  404 

cerebrospinal,  35 

congestive,  44 

contagious,  ^^ 

continued,  simple,  1 7 

dandy,  67 

enteric,  22 

entero-mesenteric,  22 

ephemeral,  17 

epidemic  cerebro-spinal,  35 

gastric,  22,  76 

hay,  306 

intermittent,  39 

irritative,  1 7 

jail,  33 

lung, 319 

malarial,  39 

malignant  intermittent,  44 

remittent,  44 
marsh,  42 
Mediterranean,  48 
nervous,  22 
neuralgic,  67 
periodical,  39 
pernicious,  4I 
relapsing,  38 
remittent,  42 
rheumatic,  219 
rose,  306 
sailors',  48 
scarlet,  5 1 
ship,  33 


617 


Fever,  simple  continued,  17 

spirillum,  38 

spotted,  2:i 

swamp,  39 

thermic,  443 

typhoid,  22 

typho-malarial,  42 

typhus,  33 

winter,  319 

yellow,  48 
Fevers,  1 5 

continued,  17 

eruptive,  51 

general  treatment  of,  1 6 

periodical,  39 

pernicious  malarial,  44 

primary  cause  of,  15 
Fibrosis,  arterio-capillary,  396 
Fish-skin  disease,  590 
Floating  kidney,  193 
Folie  circulaire,  514 
Fothergill's  disease,  479 
Freckles,  583 
Furunculosis,  569 
Furunculus,  569 

Gall-stones,  149 
Gastralgia,  94 
Gastric  cancer,  87 

carcinoma,  87 

dilatation,  90 

fever,  21,  76 

hemorrhage,  93 

neuralgia,  94 

ulcer,  84 

vertigo,  431 
Gastritis,  acute  toxic,  78 

chronic,  81 

subacute,  76 

toxic,  78 
Gastrodynia,  94 
Gastroptosis,  92 
Gastrorrhagia,  93 
General  paralysis,  521 
German  measles,  58 
Glanders,  218 
Glenard's  disease,  92 
Glossitis,  73 
Glottis,  oedema  of,  277 

spasm  of,  286 
Glycosuria,  232 


Glycosuria,  simple,  234 
Gonagra,  229 
Gout,  229 

rheumatic,  227 
Gravel,  187 
Graves'  disease,  495 
Green  sickness,  197 
Gripes,  102 
Grutum,  535 

H^MATEMESIS,  93 

Hsematology,  11 

Haematoma  of  the  dura  mater,  403 

Hsematuria,  188 

Haemophilia,  204 

Haemoptysis,  313 

Hay  asthma,  306 

fever,  306 
Headache,  434 
Heart,  anaemia  of  fatty,  199 

dilatation  of,  380 

fatty  degeneration  of,  387 

hypertrophy  of,  377 

irritable,  389 

neuralgia  of,  393 

palpitation  of,  389 

rapid,  390 

valvular  diseases  of,  369 
Heartburn,  96 
Heat  exhaustion,  444 

stroke,  443 
Hemicrania,  434 
Hemiplegia,  417 
Hemorrhage,  bronchial,  313 

cerebral,  415 

gastric,  93 

meningeal,  418 

pons,  417 

renal,  188 

ventricular,  417 
Hemorrhagic  diathesis,  204 
HemoiThoea  petechialis,  206 
Hepatic  calculi,  149 

cancer,  158 

colic,  149 
Hepatitis,  acute,  153 

general  parenchymatous,  154 

interstitial,  155 

parenchymatous,  153 

suppurative,  153 
Hernia,  strangulated,  132 


618 


INDEX. 


Herpes,  560 

circinatus,  595 

facialis,  560 

gestationis,  561 

pnvputialis,  560 

progenitalis,  560 

tonsurans,  598 

zoster,  561 
Histology,  II 
Hives,  557 

Hodgkin's  disease,  202 
Hooi)ing  coui^h,  30S 
Hydrocephalus,  acquired,  446 

acute,  407,  446 

chronic,  447 

congenital,  447 
Hydropericardium,  364 
Hydropneumothorax,  350 
Hydrosis,  537 
Hydrothorax,  350 
Hyperemia,  cerebral,  412 

renal,  167 

spinal,  449 
Hypera-mias  of  the  skin,  540 
Hyperidrosis,  537 

local,  537 

unilateral,  537 
Hypertrophies  of  the  skin,  583 
Hypertrophy,  cardiac,  377 
Hypotonia,  469 
Hysteria,  489 
Hystero-epilepsy,  492 

Ichthyosis,  590 
Icterus,  147 

hemorrhagic,  154 
Impetigo,  567 
Incubation,  period  of,  13 
Indigestion,  96 

acute,  76 

intestinal,  99 
Inebriety,  436 

Inflammation  of  the  skin,  542 
Influenza,  19 
Insanity,  507 

alternating,  515 

chronic  delusional,  520 

circular,  514 

delusional,  516 

epileptic,  513 

Kahlbaum's,  515 


Insolation,  443 
Inspection,  245 
Intercostal  neuralgia,  561 
Intermittent  fever,  39 

tetanus,  497 
Interstitial  nephritis,  175 
Intestinal  colic,  102 

dyspepsia,  99 

indigestion,  99 

obstruction,  132 

parasites,  I34 

stricture,  132 

torpor,  104 
Intestines,  diseases  of,  97 
Introduction,  9 
Invagination,  133 
Ipecacuanha  in  dysentery,  126 
Iron  lemonade,  I96 
Irritative  fever,  17 
Ischamia,  195 
Itch,  604 

barber's,  601 

Jail  fever,  53 
Jaundice,  catarrhal,  I47 
malignant,  154 

Kahlbaum's  insanity,  515 
Kakk6,  476 
Katatonia,  515 
Kidneys,  amyloid,  180 

congestion  of,  167 

contracted,  175 

diseases  of,  159 

floating,  193 

gouty,  175 

lardaceous,  1 80 

movable,  193 

sclerosis  of,  175 

small  red,  175 

wandering,  193 

waxy,  180 

white,  large,  171 

La  Grippe,  19 
Laryngeal  phthisis,  288 
laryngismus  stridulus,  286 
Laryngitis,  acute  catarrhal,  274 

croupous,  281 

oedematous,  277 

spasmodic,  279 


INDEX. 


619 


Laryngitis,  tuberculous,  288 
Larynx,  diseases  of  the,  274 
Law  of  parallelism,  220 
Lentigo,  583 
Leptomeningitis,  acute,  404 

spinalis,  452 
Lesions,  II 
Leucaemia,  201 
Leucocythemia,  201 
Lichen  simplex,  543 

tropicus,  563 
LithiEmia,  237 
Lithiasis,  237 
Liver,  abscess  of,  153 

albuminous,  157 

amyloid,  157 

atrophy  of,  156 

carcinoma  of,  158 

cirrhosis  of,  155 

congestion,  151 

diseases  of,  151 

gin  drinkers',  1 55 

hob-nailed,  155 

hypertrophic  sclerosis  of,  1 56 

lardaceous,  157 

nutmeg,  156 

sclerosis  of,  155 

scrofulous,  157 

spots,  583,  603 

torpid,  151 

waxy,  157 

yellow  atrophy  of,  154 
Lock-jaw,  498 
Locomotor  ataxia,  467 
Lousiness,  607 
Lumbago,  224 

Lumbo-abdominal  neuralgia,  480 
Lumbodynia,  224 
Lungs,  cirrhosis  of,  340 

congestion  of,  316 

consumption  of,  338 

gangrene  of,  320 

oedema  of,  317 
Lymphadenoma,  202 
Lysis,  13 

Malaria  oscillaria,  11 
Malignant  endocarditis,  367 

intermittent  fever,  44 

jaundice,  154 

remittent  fever,  44 


Mai,  le  grand,  486 
Mai,  le  petit,  487 
Malarial  fever,  39 
Mania,  507 

acute,  508 

delirious,  508 

amenorrhoeal,  509 

asthenic,  509 

chronic,  510 

dancing,  509 

delusional,  509,  516 

erotic,  509 

epileptica,  509 

hallucinatory,  509 

homicidal,  509 

post-epileptic,  513 

pre-epileptic,  513 

puerperal,  510 

reasoning,  520 

recurring,  510 

senile,  510 

transitory,  510 
Mania-a-potu,438,  509 
Marsh  fever,  42 
Measles,  56 

black,  57 

false,  58 

French,  58 

German,  58 
Mediterranean  fever,  48 
Megrim,  434 
Melansemia,  42 
Melancholia,  504 

agitata,  505 

attonita,  506 

chronic,  506 

delusional,  516 

hallucinatory,  505 

hypochondriacal,  505 

senile,  506 
Melasma  supra-renalis,  203 
Melituria,  232 
Membranous  enteritis,  112 
Meniere's  disease,  432 
Meningitis,  403 

acute,  404 

basilar,  407 

cerebrospinal,  epidemic,  35 

spinal,  452 

tubercular,  407 
Mensuration,  247 


620 


INDEX. 


Metastasis,  14 
Migraine,  434 
Miliaria,  563 

alba,  563 

rubra,  563 
Milium,  535 

Mitral  regurgitation,  369 
Mixture,  Hashani's  iron,  171 

Hrown-Sequard's,    for   epilepsy, 
4S8 

Da    Costa's     muscular    cramp, 

"4 

enterica,  11 1 

ferro  salicylata,  223 

Pepper's  asthma,  304 

Philadelphia  Hospital  epileptic, 
488 

Smith's  tonic,  I96 

Squibb's  diarrhoea,  108 
Monomania,  520 
Morbid  anatomy,  II 
Morbilli,  56 
Morphina  in  acute  urccmia,  185 

in  cardiac  dilatation,  382 
Morphiomania,  510 
Mouth,  catarrh  of,  68 

diseases  of,  68 

white,  72 
Movable  kidney,  193 
Mucus,  test  for,  161 
Muguet,  72 
Mumps,  209 
Murmurs,  aortic,  358 

endocardial,  356 

exocardial,  356 

mitral,  357 

pericardial,  356 

pulmonic,  358 

tricuspid,  358 
Muscular  rheumatism,  224 
Myelitis,  acute,  454 
Myocarditis,  acute,  383 

chronic,  384 
Myxcedema,  502 

Nasal  acute  catarrh,  263 
chronic  catarrh,  267 
passages,  diseases  of,  263 

Nephritis,  acute  desquamative,  168 
parenchymatous,  168 
catarrhal,  167 


Nephritis,   chronic   parenchymatous, 
171 

interstitial,  175 

peri-,  182 

pyelo-,  181 

suppiuative,  181 

tubal,  168 
Nephrolithiasis,  187 
Nephroptosis,  92 
Nephrosis,  pyelo  ,  182 
Nervous  dyspepsia,  97 

exhaustion,  493 

fever,  22 

prostration,  493 
Nettle-rash,  557 
Neuralgia,  479 

cervico-brachial,  480 

cervico-occipital,  480 

dorso-intercostal,  480 

intercostal,  561 

lumbo-abdominal,  480 

of  stomach,  94 

of  the  fifth  nerve,  479 

of  the  heart,  393 

red,  481 

sciatic,  480 
Neuralgic  fever,  67 
Neurasthenia,  493 
Neuritis,  multiple,  476 

simple,  475 
Neuroses,  occupation,  500 
Noma,  75 
Nomenclature,  10 
Nuclein  in  dysentery,  126 
Nymphomania,  509 
Nystagmus,  484 

Obstruction,  aortic,  373 

intestinal,  132 

mitral,  373 

pulmonic,  375 

pyloric,  87 

tricuspid,  375 
Occlusion  of  ceiebral  vessels,  42I 
Occupation  neun  ses,  500 
CEdema  of  glottis,  277 

of  lungs,  317 
OTdium  albicai  s,  72 
Oinomania,  437 
Oxyuris  vermicularis,  137 
Ozsena,  267 


\ 


INDEX. 


621 


PAr.riYMENINGITIS,  4O3 

"hypertrophic,  451 

pseudo-membranoxis,  45' 

spin^^lis,  451 
Pains,  the  girdle,  454 
Palpation,  246 
Palsy,  Bell's,  483 

shaking,  502 

wasting,  462 
Paragraphia,  429 
Paralysis,  418 

agitans,  50I 

alcoholic,  176 

bilateral,  418 

bulbar,  461 

cardiac,  213 

chronic  progressive  bulbar,  461 

crossed,  418 

diphtheritic,  213 

essential,  of  children,  458 

facial,  483 

general,  521 

glosso-labio-laryngeal,  416 

infantile  spinal,  458 

of  the  insane,  general,  521 

of  the  tongue,  430 

pharyngeal,  21 3 

shaking,  501 

spastic  spinal,  466 

unilateral,  418 

wasting,  462 
Paralytic  dementia,  521 
Paranoia,  520 
Paraphasia,  424 
Paraplegia,  ataxic,  470 
Parasites,  intestinal,  I34 
Parasitic  diseases  of  the  skin,  593 
Paresis,  general,  521 
Parkinson's  disease,  501 
Parotiditis,  209 

metastatic,  209 
Partial  cerebral  anaemia,  421 
Pathogenesis,  II 
Pathognomonic,  1 3 
Pathology,  9 
Pediculosis,  607 

capitis,  607 

corporis,  608 

pubis,  608 
Peliosis  rheumatica,  206 
Pemphigoid  purpura,  207 


Pemphigus,  565 
Peptic  ulcer,  84 
Percussion,  247 

auscultatory,  25 1 

respiratory,  251 
Perforating  ulcer,  84 
Pericarditis,  acute,  359 

chronic,  362 

dry,  359 
Pericardium,  adherent,  328 

hydro-,  329 
Peri-nephritis,  182 
Periodical  fevers,  39 
Peripheral  neuritis,  475 
Peri-proctitis,  131 
Peritoneal  dropsy,  141 
Peritonitis,  140 
Peri-typhlitis,  129 
Pertussis,  308 
Pharyngeal  paralysis,  213 
Pharyngitis,  acute  catarrhal,  269 

erysipelatous,  270 

exanthematous,  270  •« 

fibrinous,  270 

gangrenous,  270 

phlegmonous,  270,  272 
Phosphates,  tests  for,  161 
Phosphoridrosis,  537 
Phthiriasis,  607 
Phthisis,  332 

acute,  332  * 

caseous,  335 

catarrhal,  335 

chronic,  338 

fibroid,  346 

florida,  336 

incipient,  338 

laryngeal,  288 

pneumonic,  332,  335 

pulmonalis,  332 

tubercular,  332,  338 
Physical  diagnosis,  244 

signs,  12 

association  of,  263 
Pill,  Blaud's,  198 

Da  Costa's,  for  hemorrhage,  315 

England's,  198 

Gross's  neuralgic,  482 

Moussette's,  482 

Niemeyer's,  344 
Pilocarpus  fur  spreading  erysipelas,  66 


622 


INDEX. 


Pilocarpus  for  mumps,  210 
Pityriasis,  531 

versicolor,  603 
Pleurisy,  346 
Pleurilis,  346 

clironic,  347 
Pleurodynia,  225 
Pleuropneumonia,  319 

alcoholic,  322 

apyretic,  322 

aspiration,  323 
Pneumonia,  bilious,  322 

caseous,  335 

catarrhal,  328 

chronic  catarrhal,  329,  335 
interstitial,  340 

croupous,  319 

lobar,  319 

lobular,  328 

traumatic,  323 

typhoid,  322 
Pneumonitis,  319 
Pneumothorax,  350 
Podagra,  229 
Poliomyelitis  anterior  acuta,  458 

chronic,  462 
Polydipsia,  236 
Polyurin,  236 

Posterior  spinal  sclerosis,  467 
Predisposition,  12 

acquired,  12 

inherited,  12 
Prickly  heat,  563 
Primary  delusional  insanity,  516 
Proctitis,   131 

peri-,  131 
Prodromes,  13 
Professional  neuroses,  500 
Prognosis,  14 
Progressive  muscular  atrophy,  462 

jiernicious  anaemia,  199 
Pseudo-tabes,  476 
Psoriasis,  579 

circinata,  580 

diffusa.  580 

guttata,  580 

gyrata,  580 

nummularis,  580 

of  the  mouth,  74 

of  the  tongue,  74 

palmaris,  580 


Psoriasis,  plantaris,  580 

punctata,  580 

unguium,  580 
Psychalgia,  504 
Pulmonary  engorgement,  316 

wdema,  317 

tuberculosis,  332 
Pulse,  Corrigan,  371 

irregularity  of,  393 

receding,  371 
Purging,  106 
Purpura,  206 

ha^morrhagica,  206 

simplex,  206 

urticans,  206 
Pus,  test  for,  163 
Pyelitis,  l8l 
Pyelonephritis,  I  Si 
Pyelo-nephrosis,  182 
Pyloric  obstruction,  90 

stenosis,  90 
Pyrosis,  96 

QuiNiNA  in  trichinosis,  140 

in  typhoid  fever,  26 
Quinsy,  272 

malignant,  210 

Rales,  258 

Reactions  of  degeneration,  459 

Rectitis,  131 

Rectum,  catarrh  of,  131 

washing  out  the,  126 
Regurgitation,  aortic,  370 

mitral,  369 

pulmonic,  372 

tricuspid,  372 
Relapsing  fever,  38 
Remittent  fever,  42 
Renal  calculi,  187 

colic,  187 

cyst,  182 
Respiration,  Cheyne-Stokes',  388 

oscillating,  388 
Respiratory  system,  diseases  of,  244 
Rheumatic  fever,  219 

gout,  227 
Rheumatism,  acute  articular,  219 

gonorrhceal,  221 

hyperpyrexia  of,  220 


INDEX. 


623 


Rheumatism,  inflammatory,   219 

muscular,  224 
Rheumatoid  arthritis,  227 
Rhinitis,  acute,  263 

chronic,  267 
Rhinophyma,   577 
Ringworm,  honeycombed,  593 

of  the  beard,  601 

of  the  body,  595 

of  the  scalp,  598 
Rontgen  or  X  rays,  14 
Rosacea,  acne,  576 
Rose,  the,  64 
Rotheln,  58 
Round-worms,  137 
Rubella,  58 
Rubeola,  56 

Sailors'  fever,  48 

Salisbury  steaks,  83 

Sand,  renal,  188 

Scabies,  604 

Scall,  542 

Scarlatina,  51 

Scarlet  fever,  51 

Schonlein  s  disease,  207 

Sciatica,  480 

Sclerosis,  amyotrophic  lateral,  462 

antero  lateral,  470 

cerebrospinal,  471 

disseminated,  471 

hepatic  hypertrophic,  156 

of  the  liver,  155 

posterior  spinal,  467 

primary  lateral,  466 

spinal,  465,  471 
Scorbutu-,  205 
Scurvy,  205 
Sebaceous  cyst,  536 
Seborrhcea,  531 

capitis,  532 

faciei,  532 

oleosa,  532 

sicca,  532 
Secondary  processes,  13 
Secretions,  disorders  of,  53I 
Shaking  palsy,  501 
Shingles,  561 
Ship  fever,  33 
Sick  headache,  434 
Sickness,  green,  197 


Sign,  Corrigan's,  89 
Signs,  13 

physical,  association  of,  263 
Silver  nitrate  in  phlegmonous  erysip- 
elas, 67 

in  purpura  h^emorrhagica,  208 
Skin,  hypersemias  of,  540 

inflammations  of,  542 
Smallpox,  59 

Smith's,  Dr.  A.  H.,  tonic,  196 
Sore  throat,  acute,  274 
Sounds,  in  disease,  chest,  255 

in  health,  chest,  253 

normal  cardiac,  353 
Spanaemia,  195 
Spasm,  histrionic,  484 

of  the  glottis,  286 
Spasmodic  croup,  279 

tabes  dorsalis,  466 
Spastic  spinal  paralysis,  466 
Spinal  hyperemia,  449 

irritation,  493 

meningitis,  452 

sclerosis,  465 
Spinalis  pachymeningitis,  45 1 
Spotted  fever,  33 
Sprue,  72 

St.  Anthony's  fire,  64 
St.  Vitus's  dance,  484 
Stomach,  cancer  of,  87 

diseases  of,  76 

neuralgia  of,  94 

spasm  of,  94 
Stomatitis,  aphthous,  69 

catarrhal,  68 

croupous,  69 

diphtheritic,  70 

erythematous,  68 

follicular,  69 

gangrenous,  75 

parasitic,  70 

simple,  68 

ulcerative  70 

vesicular,  69 
Stonepock,  574 
Stricture,  intestinal,  132 
Strychnina  in  phthisis,  342 
Succussion,  262 
Sudamen,  539 
Sudamina,  539 
Sugar,  test  for,  164,  165 


624 


INDEX. 


Summer  complaint,  1 19 
Sunstroke,  443 
Swamp  fever,  39 
Sycosis  paralitica,  601 
Symptoms,  12 
Syncope,  419 
Synociia,  17 
Syringomyelia,  474 

Tabes  dorsalis,  467 
Tachycardia,  390 
Taenia  saginata,  134 

solium,  134 
Tapeworm,  armed,  134 

unarmed,  135 
Temulentia,  436 
Test  for  albumin,  161 

for  bile,  163 

for  bile  pigment,  164 

for  blood,  163 

for  chlorides,  161 

for  Ehrlichs  diazo-reaction,  166 

for  indican,  166 

for  mucus,  16 1 

for  phosphates,  161 

for  pus,   163 

for  sugar,  164,  165 

for  urates,  160 

for  urea,  160 
Tetanilla,  497 
Tetanus,  498 
Tetany,  286,  497 
Tetter,  542 
Thermic  fever,  443 
Throat,  acute  sore,  274 

consumption,  288 

putrid  sore,  210 
Thrombosis,  cerebral,  421 
Thrush,  72 
Tic-douloureux,  479 
Tinea  circinata,  595 

favo-a,  593 

furfuracea,  531 

kerion,  599 

sycosis,  601 

tonsurans,  598 

versicolor,  603 
Tinkling,  meiallic,  261 
Tone,  bandbox,  of  Bamberger,  304 
Tongue,  strawberr}',  52 
Tonsillitis,  acute,  272 


Tonsillitis,  catarrhal,  269 
Tormina,  102 
Torticollis,  225 
Toxic  gailritis,  78 
Trance,  492 
Treatment,  14 

abortive,  I4 

expectant,  15 

palliative,  15 

preventive,  14 

restorative,  15 
Tremens,  delirium,  438 
Trichince,  138 

spiralis,  138 
Trichinosis,  138 
Trismus,  498 

Trousseau's  diuretic  wine,  I7i 
Tubbing  in  typhoid  fever,  30 
Tubercular  meningitis,  407 
Tuberculosis,  338 

acute  miliary,  332 
Tuberculous  laryngitis,  288 
Tumor,  phantom,  492 

sebaceous,  536 
Tumors,  abdominal,  89 

intra-cranial,  426 
Turpentine  in  purpura,  208 
Tympanites,  chronic,  I46 
Typhlitis,  127 
Typho-malarial  fever,  42 
Typhoid  fever,  22 
Typhus  fever,  33 

Ulcer,  duodenal,  86 

gastric,  84 

perforating,  84 
Ulcerative  colitis,  121 

stomatitis,  70 
Ulcerosa  gingivitis,  70 
Uraemia,  acute,  183 

moqihina  in,  185 
Uncmic  coma,  183 

convulsions,  183 

intoxication,  183 
Urates,  test  for,  160 
Urea,  test  for,  160 
Uric  acid  diathesis,  237 

test  for,  160,  l6l 
Uridrosis,  537 
Urine,  159 

hysterical,  303 


625 


Urine,  normal  color,  159 
constituents,  159 
quantity,  159 
reaction,  159 
Urticaria,  557 

Vaccination,  63 

Vaccinia,  63 

Valvular  diseases  of  the  heart,  369 

diagnosis  of,  375 
Valvulitis,  364 
Varicella,  63 
Variola,  59 
Verruca,  588 
Verriicktheit,  520 
Vertigo,  431 

auditory,  431 

aural,  431 

gastric,  431 

nervous,  431 

senile,  431 

stomachic,  82,  431 
Vesicular  emphysema,  310 
Voice  in  disease,  261 

in  health,  254 
Vomit,  black,  49 

coffee-ground,  49 


Waddle,  the,  467 
Warburg's  tincture,  46 
Wart,  588 

venereal,  589 
Wasting  palsy,  462 
Water  blisters,  565 

cancer,  75 
Wen,  536 
Wlieals,  55S 
White  blood,  201 

cell  blood,  201 

mouth,  72 
Whooping-cough,  308 
Widal  reaction,  27 
Wilson's,  Erasmus,  tonic,  533 
Winter  cough,  319 
Worms,  round,  137 

seat,  137 

tape-,  134 

Xeroderma,  591 

Yellow  fever,  48 
Jack,  48 

Zona, 561 


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ner for  facilitating  study  and  reference.  It  cannot  be  sur- 
passed as  a  physician's  working  book. 

WHITE  AND  WILCOX.  Materia  Medica, 
Pharmacy,  Pharmacology,  and  Thera- 
peutics.    Fifth  Edition* 

A  Handbook  for  Students.  By  W.  Hale  White,  m.d., 
F.R.C.P.,  etc..  Physician  to,  and  Lecturer  on  Materia 
Medica  and  Therapeutics  at,  Guy's  Hospital,  etc.  Fifth 
American  Edition,  Revised  by  Reynold  W.  Wilcox, 
M.  A. ,  M.D. ,  ll.d.  ,  Professor  of  Clinical  Medicine  and  Thera- 
peutics at  the  New  York  Post-Graduate  Medical  School  and 
Hospital ;  Visiting  Physician,  St.  Mark's  Hospital ;  Assist- 
ant Visiting  Physician,  Bellevue  Hospital.     i2mo. 

Cloth,  ^3.00  ;  Leather,  ^3.50 


SUBJECT  INDEX. 

Gould's  Medical  Dictionaries,        -  Pages  12,  13 

Alorris'  Anatomy,  New  Edition,    -  -        Page    4 

Compends  for  Students,  -       -       -  -       Page  27 


BUBJECT.  PAGE 

Alimentary  Canal  (see  Sur- 
gery)     24 

Anatomy    7 

Anesthetics    18,  19 

Autopsies  (see  Pathology)  20 

Bacteriology    8 

Bandaging  (see  Surgery) .  .  24 

Blood,  I'^xamination  of...  8 

Brain 8 

Chemistry.     Physics    ....  9 

Children,  Diseases  of 11 

Climatology   19 

Clinical   Charts 25 

Compends 27 

Consumption  (.see  Lungs)  .  16 

Cyclopedia  of  Medicine.  .  .  13 

Denti.stry 11 

Diabetes  (see  Urin.  Organs)  25 

Diagnosis 11 

Diagrams  (see  Anatomy)  .  8 

Dictionaries,  Cyclopedias.  12 

Diet  and  Food 13 

Disinfection   16 

Dissectors 7 

Ear    14 

Electricity    14 

Embryology 7 

Emergencies 24 

Eye  14 

Fevers 15 

Food   13 

Formularies   21 

Gynecology    15 

Hay  Fever 25 

Heart    15 

Histology   15 

Hydrotherapy 19 

Hygiene    16 

Hypnotism 8 

Insanity 8 

Intestines 23 

Latin,  Medical   (see   Phar- 
macy)    21 

Life  Insurance 19 

Lungs 16 

Massage    17 

Materia  Medica 17 

Mechanotherapy 17 

Medical -Turisprudence. ..  .  18 


SUBJECT.  PAOB 

Mental  Therapeutics 8 

Microscopy 18 

Milk    8.  10 

Miscellaneous 18 

Nervous  Diseases 19 

No.se    25 

Nursing 20 

Obstetrics 20 

Ophthalmology 14 

Organotherapy    18 

Osteology  (see  Anatomy)  .  7 

Pathology 20 

Pharmacy 21 

Physical  Diagnosis 11 

Phy.sical  Training 17 

Physiology 22 

Pneumotherapy 19 

Poisons  (see  Toxicology)  .  .  18 

Practice  of  Medicine 22 

Prescription  Books  (Phar- 
macy)      21 

Refraction  (see  Eye) 14 

Rest    19 

Sanitary  Science 16 

Serum-Therapy 17 

Skin 23 

Spectacles  (see  Eye) .....  14 
Spine    (see    Nervous    Dis- 
eases)      19 

Stomach  23 

Students'   Compends.....  27 
Surgery  and  Surgical  Dis- 
eases     24 

Technological  Books 9 

Temperature  Charts 25 

Therapeutics    17 

Throat    25 

Toxicology 18 

Tumors  (see  Surgery)  ....  24 

U.  S.  Pharmacopoeia 22 

Urinary  Organs 25 

Urine 25 

Venereal  Diseases 26 

Veterinary  Medicine.  .....  26 

Visiting  Lists,  Physicians'. 
(Send  for  Special  Circu- 
lar.) 

Water  Analysis 16 

Women,   Diseases  of 15 


Self-Examination  tor  Medical  Students.  3500  Questions  on 
Medical  Subjects,  with  References  to  Standard  Works  in  which 
the  correct  replies  will  be  found.  Together  with  Questions 
from  State  Examining  Boards.     3d  Ed.     Paper  Osver,  10  cts. 


SUBJECT  CATALOGUE  OF  MEDICAL  BOOKS.         7 

SPECIAL  NOTE. — The  prices  given  in  this  catalogue  are 
net;  no  discount  can  be  allowed  retail  purchasers  under  any  con- 
sideration. This  rule  has  been  established  in  order  that  everyone 
will  be  treated  alike,  a  general  reduction  in  former  prices  ha\'ing 
been  made  to  meet  previous  retail  discounts.  Upon  receipt  of 
the  advertised  price  any  book  will  be  forwarded  by  mail  or 
express,  aU  charges  prepaid. 


ANATOMY.     EMBRYOLOGY. 

MORRIS.  Text-Book  of  Anatomy.  Third  Revised  and  Enlarged 
Edition.  846  Illustrations,  267  of  which  are  printed  in  colors. 
Thumb  Index  in  Each  Copy.  Cloth,  S6.00;  Leather,  $7.00 

"The  ever-growing  popularity  of  the  book  with  teichers  and 
students  is  an  index  of  its  value." — Medical  Record,  New  York. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.     2d  Edition,  Enlarged.     337  Illus.     Cloth,  $4.50 

CAMPBELL.  Dissection  Outlines.  Based  on  Morris'  Anatomy. 
2d  Edition.  .50 

DEAVER.  Surgical  Anatomy.  A  Treatise  on  Anatomy  in  its 
Application  to  Medicine  and  Surgery.  With  499  very  hand- 
some full-page  Illustrations  Engraved  from  Original  Drawings 
made  by  special  Artists  from  dissections  prepared  for  the  pur- 
pose.    Three  vols.     By  Subscription  only. 

Half  Morocco  or  Sheep,  $24.00 ;  Half  Russia,  $27.00 

GORDINIER.  Anatomy  of  the  Central  Nervous  System.  With 
271  Illustrations,  many  of  which  are  original.       Cloth,  $6.00 

HEATH.     Practical  Anatomy.    9th  Edition.    321  Illus.       $4.25 

HOLDEN.     Anatomy.    A  Manual  of  Dissections.    Revised  by  A. 
Hewson,  M.D.,  Demonstrator  of  Anatomy,  Jefferson  Medical 
CoUege,  Philadelphia.     320  handsome  Illustrations.     7th  Ed. 
In  two  compact  12mo  volumes.     850  pages.     Large  New  Type. 
Vol.  I.  Scalp — Face— Orbit — Neck — Throat — Thorax— Up- 
per Extremity.  $1.50 
Vol.  II.  Abdomen — -Perineum — Lower  Extremity — Brain — 
Eye — Ear — Mammary  Gland — Scrotum — -Testes. 

$1.50 

HOLDEN.  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the 
Muscles.  The  General  and  Microscopical  Structure  of  Bone 
and  its  Development.  With  Lithographic  Plates  and  numer- 
ous Illustrations.     8th  Edition.  $5.25 

HOLDEN.     Landmarks,  Medical  and  Surgical.    4th  Ed.  .75 

HUGHES  AND  KEITH.  Dissections.  With  527  Colored  Plates 
and  other  Illustrations.     In  three  parts. 

I,  Upper  and  Lower  Extremity.  $3.00 

II,  Abdomen— Thorax.  $3.00 

III,  Head— Neck— Central  Nervous  System.  $3.00 

LAZARUS-BARLOW.  Pathological  Anatomy.  21  Plates  and 
171  other  Illustrations.     Just  Ready.  $6.50 

MACALISTER.  Human  Anatomy,  Systematic  and  Topograph- 
ical.    816   Illustrations.  Cloth,   $5.00;  Leather,   $6.00 

McMURRICH.  Embryology,  The  Development  of  the  Human 
Body.     276  Illustrations.  $3.00 


8  SUBJECT  CATALOGUE. 

MARSHALL.  Pbysiolog:ical  Diagrams.  Eleven  Life-Sixe 
Colored  Diagrams  (each  seven  feet  by  three  feet  seven  inches). 
Designed  for  Demonstration  before  the  Class. 

In  Sheets,  Unmounted,  $40.00;  Backed  with  Muslin  and 
Mounted  on  Rollers,  $60.00;  Ditto,  Spring  Rollers,  in  hand- 
some Walnut  Wall  .Map  Case,  $100.00;  Single  Plates — Sheets, 
S5.00;  Mounted,  $7..50.  Explanatory  Key,  .60.  Purchaser 
must  pay  freight  charges. 

MINOT.  Laboratory  Text-Book  of  Embryology.  218  Illustra- 
tions.    Just  Ready.  $4.50 

POTTER.  Compend  of  Anatomy,  Including  Visceral  Anatomy. 
6th  Edition.    16  Plates  and  117  other  Illustrations. 

.80;  Interleaved,  $1.00 

WILSON.     Anatomy.    11th  Edition.    429  Illus.,  26  Plates.    $5.00 

BACTERIOLOGY. 

CONN.  Agricultural  Bacteriology.  Including  the  Study  of 
Bacteria  as  relating  to  Agriculture,  Soil,  Dairy  and  Food 
Products,  Sewage,  Domestic  Animals,  etc.    Illustrated.    $2.50 

CONN.  Bacteria  in  Milk  and  Its  Products.  Designed  for 
Students  of  Dairying,  Boards  of  Health,  Bacteriologists,  etc. 
lUustrated.  $1.25 

EMERY.  Bacteriological  Diagnosis.  2  Colored  Plates  and  32 
other  Illustrations.  $1.50 

HEWLETT.  Manual  of  Bacteriology.  75  Illustrations.  Second 
Edition,  Revised  and  Enlarged.  $4.00 

SMITH.  Laboratory  Exercises  in  Bacteriology.  A  Handbook 
for  Students.     Illustrated.  $1.50 

WILLIAMS.  Bacteriology.  A  Manual  for  Students.  90  Illus- 
trations.    2d  Edition,  Revised.  $1.50 

BLOOD,  Examination  of. 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  the 
Examination  of  the  Blood,  with  Reference  to  Diagnosis.  Six 
Colored  Plates  and  48  other  Illus.       Cloth,  $5.00 ;  Sheep,  $6.00 

BRAIN  AND  INSANITY  (see  also 
Nervous  Diseases.) 

BLACKBURN.  A  Manual  of  Autopsies.  Designed  for  the  Use 
of  Hospitals  for  the  Insane  and  other  Public  Institutions.  Ten 
full-page  Plates  and  other  Illustrations.  $1.25 

CHASE.     General  Paresis.     Illustrated.  $1.75 

DERCUM.  Mental  Therapeutics,  Rest,  Suggestion.  See  Cohen, 
Physiologic  Therapeutics,  page  17. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central 
Nervous  System.     With  full-page  and  other  Illus.         $6.00 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous   Illustrations.  $2. .50 

IRELAND.     The  Mental  Affections  of  Children.     2d  Ed.     $4.00 

LEWIS  (BE VAN).  Mental  Diseases.  A  Text-Book  having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.  26 
Lithographic  FLates  and  other  illustrations.     2d  Ed.     $7.00 


MEDICAL  BOOKS. 


MAUN.     Manual  of  Psychological  Medicine.  $3.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Disease.  Illus- 
trated. SI. 25 

REGIS.  Mental  Medicine.  Authorized  Translation  by  H.  M. 
Bannister,  m.d.  $2.00 

SCHOFIELD.     The  Force  of  Mind.  S2.00 

STEARNS.  Mental  Diseases.  With  a  Digest  of  Laws  Relating 
to  Care  of  Insane.    Illustrated.         Cloth,  S2.7.5 ;  Sheep,  S3.25 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the 
Definition,  Etymology,  and  Symptoms  of  the  Terms  used  in 
Medical  Psychology,  with  the  Symptom?,  Pathology,  and 
Treatment  of  the  Recognized  Forms  of  Jlental  Disorders. 
Two  volumes.  SIO.OO 

WOOD,  H.  C.     Brain  and  Overwork.  .40 

CHEMISTRY  AND   TECHNOLOGY. 

Special  Catalogue  of  Chemical  Books  sent  free  upon  application. 

ALLEN.  Commercial  Organic  Analysis.  A  Treatise  on  the 
Modes  of  Assaying  the  Various  Organic  Chemicals  and  Prod- 
ucts Employed  in  the  Arts,  Manufactures,  Medicine,  etc., 
with  Concise  Methods  for  the  Detection  of  Impurities,  Adul- 
terations, etc.     8vo. 

Vol.  I.    Alcohols,  Neutral  Alcoholic  Derivatives,  etc.,  Ethers, 
Vegetable  Acids,  Starch,  Sugars,  etc.     3d  Edition.     S4.50 
Vol.  II,  Part  I.     Fixed  Oils  and  Fats,  Glycerol,  Explosives, 
etc.     3d  Edition.  S3.50 

Vol.  II,  Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants, 
Benzenes,  Naphthalenes  and  Derivatives,  Creosote,  Phenols, 
etc.     3d  Edition.  S3. 50 

Vol.  II,  Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors, 
etc.     3d  Edition.  Preparing. 

Vol.  Ill,  Part  I.  Tannins,  Dyes,  and  Coloring  Matters.  3d 
Edition,  Enlarged   and   Rewritten.      Illustrated.  S4.50 

Vol.  Ill,  Part  II.  The  Amines,  Hydrazines  and  Derivatives, 
Pyridine  Bases.  The  Antipyretics,  etc.  Vegetable  Alka- 
loids, Tea,  Coffee,  Cocoa,  etc.  8vo.  2d  Edition.  S4.50 
Vol.  Ill,  Part  III.  Vegetable  Alkaloids,  Non-Basic  Vegetable 
Bitter  Principles.  Animal  Bases,  Animal  Acids,  Cyanogen 
Compounds,  etc.     2d  Edition,  8vo.  S4.50 

Vol.  IV.  The  Proteids  and  Albuminous  Principles.  2d 
Edition.  '  S4.50 

BAILEY  AND  CADY.     Qualitative  Chemical  Analysis.       SI. 25 
HARTLEY.     Medical  and  Pharmaceutical  Chemistry.     A  Text- 
Book  for  Medical,  Dental,  and  Pharmaceutical  Students.   With 
Illustrations,  Glossary,  and  Complete  Index.    5th  Ed.     S3. 00 
BARTLEY.     Clinical   Chemistry.     The   Examination  of   Feces, 
Saliva,  Gastric  Juice,  Milk,  and  Urine.  Sl.OO 

BLOXAM.     Chemistry,  Inorganic  and  Organic.     With  Experi- 
ments.    9th  Ed.,  Revised.     281  Engravings.  Preparing. 
BUNGE.      Physiologic    and   Pathologic    Chemistry.     From    the 
Fourth  German  Enlarged  Edition.  S3. 00 
CALDWELL.     Elements  of  Qualitative  and  Quantitative  Chem- 
ical Analysis.     3d  Edition,  Revised.  Sl.OO 
CAMERON.     Oils  and  Varnishes.     With  Illustrations.         S2.25 


10  SUBJECT  CATALOGUE. 


CAMERON.     Soap  and  Candles.     54  Ulustrntiona.  $2.00 

CLOWES  AND  COLEMAN.  Quantitative  Analysis.  5th  Edi- 
tion.     1-22  lllustnitions.  S.^J.-W 

COBLENTZ.     Volumetric  Analysis.     Illustrated.  $1.25 

CONGDON.  Laboratory  Instructions  in  Chemistry.  With 
Numerous  Tables  and  50  Illustrations.  $1.00 

GARDNER.  The  Brewer,  Distiller,  and  Wine  Manufacturer. 
Illustrated.  $1.50 

GRAY.  Physics.  Volume  I.  Dynamics  and  Properties  of 
Matter.     :W0  Illustrations.  $4.50 

GROVES  AND  THORP.     Chemical  Technology.     The  Applica- 
tion of  Chemistry  to  the  Arts  and  Manufactures. 
Vol.  I.  Fuel  and  its  Applications.     607  Illustrations  and  4 
Plates.  Cloth,  $5.00;  i  Mor..  $6.50 

Vol.11.    LightinK.     Illustrated.        Cloth,  S4.00;  i  Mor.,  $5.60 
Vol.  III.  Gas  Lightine.  Cloth,  $3.50;  i  Mor.,  $4.50 

Vol.  IV.  Electric  Lighting.     Photometry. 

Cloth,  $3.50;  i  Mor.,  $4..';0 

HEUSLER.     The  Chemistry  of  the  Terpenes.  $4.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Micro- 
scopical, for  I>aboratory  Use.     Cth  Ed.     Illustrated.       $1.00 

LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic  and 
Organic.     4th   Edition,   Revii?ed.  .80;  Interleaved,  SI. 00 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  2d  Edition, 
Enlarged.     Illustrated.  $1.25 

LEFFMANN.  Water  Analysis.  For  Sanitary  and  Technic  Pur- 
poses.    Illustrated.     4th  Edition.  $1.25 

LEFFMANN.  Structural  Formula.  Including  ISO  Structural 
and  Stereo-Chemical  Formute.     r2mo.     Interleaved.       $1.00 

LEFFMANN  AND  BEAM.  Select  Methods  in  Food  Analysis. 
Illustrated.  $2.50 

MUTER.  Practical  and  Analytical  Chemistry.  2d  American 
from  the  Eighth  P",nglish  Edition.  Revised  to  meet  the  re- 
quirements of  American  Students.     56  Illustrations.        $1.25 

OETTEL.     Exercises  in  Electro-Chemistry.    Illustrated.  .75 

OETTEL.     Electro-Chemical  Experiments.     Illustrated.  .75 

RICHTER.  Inorganic  Chemistry.  5th  American  from  10th 
German  Edition.  Authorized  translation  by  Edgar  F.  Smith, 
M.A  ,  PH.D.     89  Illustrations  and  a  Colored  Plate.  $1.75 

RICHTER.  Organic  Chemistry.  3d  American  Edition,  trans- 
lated from  the  8th  German  by  Edgar  F.  Smith.  Illus.  2  vols. 
Vol.    I.  Aliphatic  Series.     625  pages.  $3.00 

Vol.  II.  Carbocyclic  Series.     671  pages.  $3.00 

ROCKWOOD.  Chemical  Analysis  for  Students  of  Medicine, 
Dentistry,  and  Pharmacy.     Illustrated.  $1.50 

SMITH.     Electro-Chemical  Analysis.     3d  Ed.  39  Illus.     $1.50 

SMITH  AND  KELLER.  Experiments.  Arranged  for  Students 
in  General  Chemistry.    4th  Edition.    Illustrated.  .60 

SUTTON.  Volumetric  Analysis.  A  Systematic  Handbook  for 
the  Quantitative  Estimation  of  Chemical  Substances  by 
Measure,  Applied  to  Liquids,  Solids,  and  Gases.  8th  Edition, 
Revised.     112  Illustrations.  $5.00 

SYMONDS.     Manual  of  Chemistry.     2d  Edition.  $2.00 

TRAUBE.     Physico-Chemical  Methods.    97  Illustrations.    $1.50 


MEDICAL  BOOKS.  11 

THRESH.     Water  and  Water  Supplies.     3d  Edition.  $2.00 

ULZER    AND    FRAENKEL.        Chemical    Technical    Analysis. 

Translated  by  Fleck.     Illustrated.  $1.25 

WOODY.     Essentials  of  Chemistry  and  Urinalysis.    4th  Edition. 

Illustrated.  $1.50 

***  Special  Catalogue  of  Books  on  Chemistry  free  upon  application. 

CHILDREN. 

HATFIELD.     Compend    of    Diseases    of     Children.     With    a 
Colored  Plate.    3d  Ed.    Just  Ready.       .80;  Interleaved,  $1.00 
IRELAND.     The   Mental  Affections  of   Children.     Idiocy,   Im- 
becility, Insanity,  etc.     2d  Edition.  $4.00 
POWER.     Surgical  Diseases  of   Children  and  their  Treatment 
by  Modem  Methods.     Illustrated.  $2.50 
STARR.     The  Digestive  Organs  in  Childhood.     The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.     3d  Edition, 
Rewritten  and  Enlarged.     Illustrated.  $3.00 
STARR.     Hygiene  of  the  Nursery.     Including  the  General  Regi- 
men and  Feeding  of  Infants,  and  Children,  and  the  Domestic 
Management   of   the   Ordinary   Emergencies   of   Early   Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  $1.00 
SMITH.     Wasting  Diseases  of  Children.     6th  Edition.  $2.00 
TAYLOR  AND  WELLS.     The  Diseases  of  Children.     2d  Edition, 
Revised  and  Enlarged.     Illustrated.     8vo.  $4.50 
"It  is  well  worthy  the  careful  study  of  both  student  and  prac- 
titioner, and  can  not  fail  to  prove  of  great  value  to  both.     We 
do  not  hesitate  to  recommend  it." — Boston  Medical  and  Surgical 
Journal. 

DIAGNOSIS. 

BROWN.  Medical  Diagnosis.  A  Manual  of  Clinical  Methods. 
4th  Edition.     112  Illustrations.  Cloth,  $2.25 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  Exam- 
ination of  Blood,  with  Reference  to  Diagnosis.  6  Colored 
Plates,  48  other  Illustrations.  Cloth,  $5.00 ;  Sheep,  $6.00 

DOUGLAS.  Surgical  Diseases  of  Abdomen,  with  Reference  to 
Diagnosis.     20  Full-Page  Plates.     Just  Ready. 

Cloth,  $7.00  ;  Sheep,  $8.00 

EMERY.  Bacteriological  Diagnosis.  2  Colored  Plates  and  32 
other  Illustrations.  $1.50 

MEMMINGER.    Diagnosis  by  the  Urine.    2d  Ed.    24  Illus.    $1.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases. 
Illustrated.  $1.25 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  $1.25 

TYSON.  Handbook  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Medicine  in  the  Uni- 
versity of  Pennsylvania.  Illus.  4th  Ed.,  Improved  and  En- 
larged.    With  2  Colored  and  55  other  Illustrations.  $1.50 

DENTISTRY. 

Special  Catalogue  of  Dental  Books  sent  free  upon  application. 
BARRETT.     Dental    Surgery    for    General    Practitioners    and 
Students  of  Medicine  and  Dentistry.     Extraction  of  Teeth, 
ete.     3d  Edition.     Illustrated.  $1.00 


12  SUBJECT  CATALOGUE. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.  Second  Edition,  Revised  and  Enlarged.  337 
handsome  Illustrations.  Cloth,  §4.50 ;  Leather,  $.5.50 

FILLEBROWN.      Operative  Dentistry.    Illustrated.  $2.25 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition.  Cloth,  84.00;  Sheep,$5.00 

GORGAS.  Questions  and  Answers  for  the  Dental  Student. 
Embracing  all  the  subjects  in  the  Curriculum  of  the  Dental 
Student.     Octavo.  S6.00 

HARRIS.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Sur- 
gery, and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S. 
GoRGAS,  M.D.,  D.D.a.     1250  Illus.    Cloth,  S6.00 ;  Leather,  S7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the 
Ajt  and  Practice  of  Dentistry.  6th  Edition,  Revised  and 
Enlarged  by  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s. 

«     Cloth,  S5.00 ;  Leather,  S6.00 

RICHARDSON.  Mechanical  Dentistry.  7th  Edition.  Thor- 
oughly Revised  and  Enlarged  by  Dr.  Geo.  W.  Warren.  691 
Illustrations.  Cloth,  S5.00;  Leather,  S6.00 

SMITH.     Dental  Metallurgy.    2d  Edition.    Illustrated.  $2.00 

TAFT.    Index  of  Dental  Periodical  Literature.  S2.00 

TOMES.     Dental  Anatomy.     263  Illustrations.     5th  Ed.  $4.00 

TOMES.     Dental  Surgery.     4th  Edition.     289  lUus.  $4.00 

WARREN.  Compend  of  Dental  Pathology  and  Dental  Medicine. 
With  a  Chapter  on  Emergencies.    3d  Edition.    Illustrated. 

.80;  Interleaved,  Sl.OO 

WARREN.     Dental  Prosthesis  and  Metallurgy.    129  Illus.    $1.25 

WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 

DICTIONARIES.     CYCLOPEDIAS. 

GOULD.  The  Illustrated  Dictionary  of  Medicine,  Biology,  and 
Allied  Sciences.  Being  an  Exhaustive  Lexicon  of  Medicine  and 
those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistrj',  Pharmacology,  Microscopy,  etc.,  with 
many  useful  Tables  and  numerous  fine  Illustrations.  1633 
pages.     Fifth  Edition. 

Sheep  or  Half  Morocco.  $10.00;  with  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12.00 

GOULD.  The  Medical  Student's  Dictionary,  nth  Edition.  Il- 
lustrated. Including  those  Words  and  Phrases  generally  used 
in  Medicine,  with  their  Proper  Pronunciation  and  Definition, 
Based  on  Recent  Medical  Literatm-e.  With  Table  of  Epo- 
nymic  Terms  and  Tests  and  Tables  of  the  BacUli,  Micrococci, 
Mineral  Springs,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia, 
Plexiises,  etc.  Eleventh  Edition.  Enlarged  and  illustrated 
with  a  large  number  of  Engravings.    840  pages. 

Half  Morocco,  $2.50 ;  with  Thumb  Index,  $3.00 


MEDICAL  BOOKS.  13 

GOULD.  The  Pocket  Pronouncing  Medical  Lexicon.  4th  Edi- 
tion. (30,000  Medical  Words  Pronounced  and  Defined.)  Con- 
taining all  the  Words,  their  Definition  and  Pronunciation, 
that  the  Medical,  Dental,  or  Pharmaceutical  Student  Gener- 
ally Comes  in  Contact  with;  also  Elaborate  Tables  of  Epo- 
nymic  Terms,  Arteries,  Muscles,  Nerves,  BacUli,  etc.,  etc.,  a 
Dose  List  in  both  English  and  Metric  Systems,  etc.,  Arranged 
in  a  Most  Convenient  Form  for  Reference  and  Memorizing. 
Fourth  Edition,  Revised  and  Enlarged.  838  pages. 
Full  Limp  Leather,  Gilt  Edges,  SI. 00;  Thumb  Index,  $1.25 
145,000  Copies  of  Gould's  Dictionaries  have  been  sold. 

GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  Seventy-two  Special  Contributors.  Illustrated.  One 
Voltime.  A  Concise  Reference  Handbook  of  Medicine,  Sur- 
gery, Obstetrics,  Materia  Medica,  Therapeutics,  and  the  Vari- 
ous Specialties,  with  Particular  Reference  to  Diagnosis  and 
Treatment.  Compiled  under  the  Editorial  Supervision  of 
George  M.  Goitld,  m.d.,  Author  of  "An  Illustrated  Dictionary 
of  Medicine,"  etc.;  and  Waiter  L.  Pn,E,  m.d.,  Assistant 
Surgeon  Wills  Eye  Hospital;  formerly  Editor  "International 
Medical  Magazine,"  etc.,  and  Seventy-two  Special  Contribu- 
tors. With  many  Illustrations.  Large  Square  8vo,  to  corre- 
spond with  Gould's  "Illiistrated  Dictionary." 
Full  Sheep  or  Half  Mor.,  SIO.OO;  -svith  Thumb  Index,  SI  1.00 
Half  Russia,  Thumb  Index,  S12.00  net. 

GOULD  APTD  PYLE.  Pocket  Cyclopedia  of  Medicine  and  Sur- 
gery. Based  upon  above  book  and  uniform  in  size  with 
"Gould's  Pocket  Dictionary." 

Full  Limp  Leather,  GUt  Edges,  $1.00 
W^ith  Thumb  Index,  SI. 25 

HARRIS.  Dictionary  of  Dentistry.  Includiog  Definitions  of 
Such  Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain 
to  the  Art  and  Practice  of  Dentistry.  6th  Edition,  Revised 
and  Enlarged  by  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s. 

Cloth,  $5.00 ;  Leather,  $6.00 

LONGLEY.     Pocket  Medical  Dictionary.  Cloth,  .75 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr.  Theo- 
dore Maxwell,  Assisted  by  Others.  $3.00 
The  object  of  this  work  is  to  assist  the  medical  men  of  any 

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their  own.     Each  term  is  usually  given  in  seven  languages,  viz. : 

English,  French,  German,  Italian,  Spanish,  Russian,  and  Latin. 

TREVES  AND  LANG.     Geiman-EngUsh  Medical  Dictionary. 

Half  Calf,  $3.25 

DIET  AND  FOOD. 

ALLEN.  Proteids  and  Albuminous  Principles.  An  analytical 
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BURNETT.  Foods  and  Dietaries.  A  Manual  of  Clinical  Diet- 
etics, with  Diet  Lists  for  Various  Diseases,  etc.     2d  Ed.     $1.50 

DAVIS.  Dietotherapy.  Food  in  Health  and  Disease.  With 
Tables  of  Dietaries,  Relative  Value  of  Foods,  etc.  See  Cohen, 
Physiologic  Therapeviics,  page  17. 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated..  In  Press. 

HAIG.  Diet  and  Food.  Considered  in  Relation  to  Strength  and 
Power  of  Endurance.     4th  Edition.  $1.00 

LEFFMANN.     Select  Methods  in  Food  Analysis.     lUus.         $2.50 


14  SUBJECT  CATALOGUE. 

EAR  (see  also  Throat  and  Nose). 

BURNETT.     Hearing  and  How  to  Keep  It.     lllu.strated.  .40 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynx.  Including 
Anatomy  and  I'hy.'iioloKy  of  tlie  Organ,  toRcther  with  the 
Treat iiiciit  of  the  Affections  of  the  Nose  and  Pliarynx  which 
('oniliice  to  Aural  IJisease.  128  lUu-strations.  2d  Ed.  $5.50 
PRITCHARD.  Diseases  of  the  Ear.  4th  Edition,  Enlarged. 
Many  Illustration.s  and  I'oriTiuhc.  In  Preta. 

ELECTRICITY. 

BIGELOW.     Plain  Talks  on  Medical  Electricity  and  Batteries. 

With  a  Therapeutic  Index  and  a  Glossary.     43  Illustrations. 

2d  Edition.  $1.00 

HEDLEY.     Therapeutic  Electricity  and  Practical  Muscle  Testing. 

99  Illustrations.  $2.50 

JACOBY.     Electrotherapy.    2  volumes.    Illustrated.    See  Cohen, 

Physiologic  Therapeutics,  page  17. 
JONES.     Medical  Electricity.     3d  Edition.     117  Illus.         $3.00 

EYE. 

A  Special  Circular  of  Books  on  the  Eye  sent  free  upon  application. 

DARIER.     Ocular  Therapeutics.  Nearly  Ready. 

DONDERS.  The  Nature  and  Consequences  of  Anomalies  of 
Refraction.     With  Portrait  and  Illus.         Half  Morocco,  $1.25 

PICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Translated 
by  A.  B.  Hale,  m.d.     157  Illus.     Cloth,  $4.50;   Sheep.  $5.50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and  Re- 
fraction. Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formula;,  Useful  Tables,  a 
Glossary,  and  111  Illus.,  several  of  which  are  in  colors.  2d 
Edition,  Revised.  Cloth,  .80;  Interleaved,  $1.00 

GREEFF.  The  Microscopic  Examination  of  the  Eye.  Illus- 
trated. $1.25 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illus.  .40 

HARTRIDGE.  On  the  Ophthalmoscope.  4th  Edition.  With 
4  Colored  Plates  and  68  Wood-cuts.  $1.60 

HARTRIDGE.  Refraction.  104  Illustrations  and  Test  Types. 
11th  Edition,  Enlarged.  $1.50 

HANSELL  AND  SWEET.  Treatise  on  Diseases  of  the  Eye. 
With  many  Illus.  drawn  by  special  artists,  etc.  In  Press. 

HANSELL  AND  REBER.  Muscular  Anomalies  of  the  Eye. 
lUustrated.  $1.50 

HANSELL  AND  BELL.  Clinical  Ophthahnology.  Colored 
Plate  of  Normal  Fundus  and  120  Illustrations.  $1.50 

JENNINGS.  Manual  of  Ophthalmoscopy.  95  Illu-strations  and 
1  Colored  Plate.  $1.50 

MORTON.  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Cor- 
rection of  its  Errors.     6th  Editi^.  $1.00 

OHLEMANN.  Ocular  Therapeutics.  Authorized  Translation, 
and  Edited  by  Dr.  Charles  A.  Oliver.  $1.75 

PARSONS.  Elementary  Ophthalmic  Optics.  With  Diagram- 
matic Illustrations.  $2.00 


MEDICAL  BOOKS.  15 


PHILLIPS.  Spectacles  and  Eyeglasses.  Their  Prescription 
and  Adjustment.     3d  Edition.     52  Illustrations.  SI. 00 

SWANZY.  Diseases  of  the  Eye  and  Their  Treatment.  7th 
Edition,  Revised  and  Enlarged.  164  Illustrations,  1  Plain 
Plate,  and  a  Zephyr  Test  Card.  $2.50 

From.  The  Medical  News. 

' '  Swanzy  has  succeeded  in  producing  the  most  intellectually 

conceived  and  thoroughly  executed  rfeum^  of  the  science  within 

the  limits  he  has  assigned  himself.     As  a  'student's  handbook,' 

small  in  size  and  of  moderate  price,  it  can  hardly  be  equaled." 

THORINGTON.  Retinoscopy.  4th  Edition,  Carefully  Revised. 
Illustrated.  SI. 00 

THORINGTOUr.  Refraction  and  How  to  Refract.  200  Illustra- 
tions, 13  of  which  are  colored.     2d  Edition.  $1.50 

WALKER.  Student's  Aid  in  Ophthalmology.  Colored  Plate 
and  40  other  Illustrations  and  a  Glossary.  $1.50 

WORTH.     Squint :   Its  Causes,  Pathology,  and  Treatment. 

Nearly  Ready. 

WRIGHT.  Ophthalmology.  2d  Edition,  Revised  and  Enlarged. 
117  Illustrations  and  a  Glossary.  S3. 00 

FEVERS. 

GOODALL  AND  WASHBOURN.  Fevers  and  Their  Treatment. 
Illustrated.  $3.00 

GYNECOLOGY. 

BISHOP.  Uterine  Fibromyomata.  Their  Pathology,  Diag- 
nosis, and  Treatment.     Illustrated.  Cloth,  S3. 50 

BYFORD  (H.  T.).  Manual  of  Gynecology.  3d  Edition,  Revised 
and  Enlarged.     363  Illustrations.  S3.00;  Sheep,  S3.50 

DtfHRSSEN.  A  Manual  of  Gynecological  Practice.  105  Illu-s- 
trations.  SI. 50 

FULLERTON.  Surgical  Nursing.  3d  Edition,  Revised  and 
Enlarged.     69  Illustrations.  $1.00 

LEWERS.     Diseases  of  Women.     146  lUus.     5th  Ed.  S2.50 

LEWERS.     Cancer  of  the  Uterus.     Just  Ready.  $3.00 

MONTGOMERY.  Practical  Gynecology.  A  Complete  Sys- 
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ROBERTS.  Gynecological  Pathology.  With  127  FuU-page 
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WELLS.  Compend  of  Gynecology.  Illustrated.  3d  Edition, 
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HEART. 

THORNE.  The  Schott  Methods  of  the  Treatment  of  Chronic 
Heart  Disease.     Fourth  Edition.     Illustrated.  $2.00 

HISTOLOGY. 

GUSHING.  Compend  of  Histology.  By  H.  H.  Gushing,  m.d., 
Demonstrator  of  Histology,  Jefferson  Medical  College,  Phila- 
delphia.    Illus.     Nearly  Ready.  .80;  Interleaved,  $1.00 

LAZARUS-BARLOW.  Pathological  Anatomy  and  Histology. 
lUustrated.  $6.50 


16  SUBJECT  CATALOGUE. 


STIRLING.  Outlines  of  Practical  Histology.  368  Illastrations. 
2d  Edition,  Revised  and  linliirKed.     With  new  Illus.         $2.00 

STOHR.  Histology  and  Microscopical  Anatomy.  Edited  by 
A.  ScHAPER,  M.D.,  Univcr.-iity  of  Hrcslau,  formerly  Deruon- 
strator  of  Histology,  Harvard  Medical  School.  Fourth  Amer- 
ican from  9th  German  Edition,  Revised  and  Enlarged.  379 
Illustrations.  S3.00 

HYGIENE. 

Special  Catalogue  of  Books  on  Hygiene  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
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CONN.     Bacteriology  of  Milk  and  Milk  Products.     Illus.     $1.25 

COPLIN.  Practical  Hygiene.  A  Complete  American  Text- 
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ELARTSHORNE.     Our  Homes.     Illustrated.  .40 

KENWOOD.  Public  Health  Laboratory  Work.  116  Illustra- 
tions and  3  Plates.  $2.00 

LEFFMANN.  Select  Methods  in  Food  Analysis.  53  Illustra- 
tions and  4  Plates.  $2.50 

LEFFMANN.  Examination  of  Water  for  Sanitary  and  Technical 
Purposes.     4th  Edition.     Illustrated.  $1.25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illustrated. 
Second  Edition.  $1.25 

LINCOLN.     School  and  Industrial  Hygiene.  .40 

McFARLAND.  Prophylaxis  and  Personal  Hygiene.  Care  of 
the  Sick.     See  Cohen,  Physiologic  Therapeutics,  page  17. 

NOTTER.  The  Theory  and  Practice  of  Hygiene.  15  Plates  and 
138  other  Illustrations.     8vo.     2d  Edition.  $7.00 

PARKES  AND  KENWOOD.  Hygiene  and  PubUc  Health.  2d 
Edition,  Enlarged.     Illustrated.  $3.00 

ROSENAU.     Disinfection  and  Disinfectants.     Illus.  $2.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
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tic Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  $1.00 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
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Vol.  I,  S6.00;  Vol.  II,  $6.00;  Vol.  Ill,  $5.00 

THRESH.     Water  and  Water  Supplies.     3d  Edition.  $2.00 

WILSON.  Handbook  of  Hygiene  and  Sanitary  Science.  With 
Illustrations.     8th  Edition.  $3.00 

WEYL.  Sanitary  Relations  of  the  Coal- Tar  Colors.  Authorized 
Translation  by  Henrt  Leffmann,  m.d.,  ph.d.  $1.25 

LUNGS  AND  PLEURAE. 

KNOPF.    Pulmonary  Tuberculosis.     Its  Modern  Prophylaxis  and 

Treatment  in  Special  Institutions  and  at  Home.    Illus.    $3.00 

STEELL.     Physical  Signs  of  Pulmonary  Disease.     Illus.       $1.25 


MEDICAL  BOOKS.  17 


MASSAGE.     PHYSICAL  EXERCISE. 

OSTROM.  Massage  and  the  Original  Swedish  Movements. 
Their  Application  to  Various  Diseases  of  the  Body.  A  Manual 
for  Students,  Nurses,  and  Physicians.  Fifth  Edition,  En- 
larged.    115  Illustrations,  many  of  which  are  original.     Sl.OO 

MITCHELL  AND  GULICK.  Mechanotherapy.  Physical  Edu- 
cation, Orthopedic  Appliances,  etc.  Illustrated.  See  Cohen, 
Physiologic   Therapeutics,  below. 

TREVES.     Physical  Education.     Its  Value,  Methods,  etc.        .75 

MATERIA  MEDICA  AND  THERAPEUTICS. 

BRACKEN.  Outlines  of  Materia  Medica  and  Pharmacology.  $2.75 
COBLENTZ.     The  Newer  Remedies.     Including  their  Synonyms, 
Sources,  Methods  of  Preparation,  Tests,  Solubilities,  Doses, 
etc.     3d  Edition,  Enlarged  and  Revised.  $1.00 

COHEN.  Physiologic  Therapeutics.  Methods  other  than  Drug- 
Giving  useful  in  the  Prevention  of  Disease  and  in  the  Treat- 
ment of  the  Sick.  Mechanotherapy,  Mental  Therapeutics, 
Suggestion,  Electrotherapy,  _  Climatology,  Hydrotherapy, 
Pneumatotherapy,  Prophylaxis,  Dietetics,  Organotherapy, 
Phototherapy,  Mineral  Waters,  Baths,  etc.  11  volumes,  8vo. 
Illustrated.     (Subscription.)  Cloth,  $27.50;  i  Mor.,  $38.50 

Special  Descriptive  Circular  will  be  sent  upon  application. 
GORGAS.     Dental  Medicine.     A  Manual  of  Materia  Medica  and 
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GROFF.  Materia  Medica  for  Nurses,  with  Questions  for  Self- 
Examination.     2d  Edition,  Revised  and  Improved.  $1.25 

HELLER.     Essentials  of  Materia  Medica,  Pharmacy,  and  Pre- 
scription Writing.  $1.50 
HEWLETT.     Serum-Therapy.                                             In  Press. 
MAYS.     Theine  in  the  Treatment  of  Neuralgia,     i  bound.       .50 
POTTER.     Handbook  of  Materia  Medica,  Pharmacy,  and  Thera- 
peutics, including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and 
Formulae.     9th  Edition,  Revised  and  Enlarged.     With  Thumb 
Index  in  each  copy.     Just  Ready.      Cloth,  $5.00 ;  Sheep,  $6.00 
' '  In  conclusion  we  may  add  that  Dr.  Potter's  Therapeutics 
covers  a  wider  field  than  many  books  which  bear  this  title.    He 
discusses  a  good  rnany  drugs  which  are  rarely  employed,  and 
therefore  the  book  is  as  useful  to  one  who  wishes  to  look  for  un- 
usual information  as  it  is  to  him  who  wishes  a  handbook  for  ready 
reference  in  the  treatment  of  disease  as  he  meets  it  from  day  to 
day." — Therapeutic  Gazette. 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and  Pre- 
scription Writing,  with  Special  Reference  to  the  Physiological 
Action  of  Drugs.     6th  Edition.  .80;  Interleaved,  $1.00 

MURRAY.     Rough  Notes  on  Remedies.     4th  Edition.  $1.25 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the 
Vegetable  and  Animal  Drugs.  Comprising  the  Botanical  and 
Physical  Characteristics,  Source,  Constituents,  and  Pharma- 
copeial  Preparations,  Insects  Injurious  to  Drugs,  and  Pharma- 
cal  Botany.  With  sections  on  Histology  and  Microtechnique, 
by  W.  C.  Stevens.  374  Illustrations,  many  of  which  are 
original.     2d  Edition.  Cloth,  $4.50 


18  SUBJECT  CATALOGUE. 


TAVERA.     Medicinal  Plants  of  the  Philippines.  $2.00 

WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Pharma- 
cology, and  Therapeutics.  .5th  .\inerican  lOilition,  Revised  by 
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Medicine  and  Tlierapeutics  at  the  New  York  Post-Oraduate 
Medical  School.  Cloth.  $3.00 ;  Leather.  $.3.50 

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conspicuous  on  every  page,  and  it  is  evident  that  no  recent  drug 
pos.se.ssin^  any  merit  has  escaped  his  eye.  We  believe,  on  the 
whole,  this  is  tlie  best  hook  on  Materia  Medica  and  Therapeutics 
to  place  in  the  hands  of  students,  and  the  practitioner  will  find  it 
a  most  satisfactory  work  for  daily  use." — The  Cleveland  Medical 
Qazettc. 

MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

REESE.  Medical  Jurisprudence  and  Toxicology.  A  Text-Book 
for  Medical  and  Legal  Practitioners  and  Students.  6th 
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Cloth.  S3.00;  Leather,  $3.50 
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invaluable,  as  it  is  concise,  clear,  and  thorough  in  every  respect." 

— The  American  Journal  oj  the  Sledical  Sciences. 

MANN.     Forensic  Medicine  and  Toxicology.     lUus.  $6.50 

TANNER.  Memoranda  of  Poisons.  Their  Antidotes  and  Tests. 
9th  Edition,  by  Dr.  Henry  Leff.mann.     Just  Ready.         .75 

MICROSCOPY. 

CARPENTER.  The  Microscope  and  Its  Revelations.  8th 
Edition,  Revised  and  Enlarged.  817  Illustrations  and  23 
Plates.  Cloth.  SS.OO;  Half  Morocco.  $9.00 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated.  In  Press. 

LEE.  The  Microtomist's  Vade  Mecum.  A  Handbook  of 
Methods  of  Microscopical  Anatomy.  887  Articles.  5th 
Edition.  Enlarged.  $4.00 

OERTEL.  Medical  Microscopy.  A  Guide  to  Diagnosis,  Ele- 
mentary Laboratory  Methods  and  Microscopic  Technic.  131 
Illustrations.     Just  Ready.  $2.00 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology. Neoplasms.  Urinary  Examination,  etc.  Numerous 
Illustrations,  some  of  which  are  printed  in  colors.  $2.50 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the 
Microscope  in  Practical  Medicine.     100  Illustrations.        $2.00 

MISCELLANEOUS. 

BERRY.     Diseases  of  Thyroid  Gland.     Illustrated.  $4.00 

BUXTON.     Anesthetics.     Illustrated.     3d  Edition.  $1.50 

COHEN.     Organotherapy.    See  Cohen,  Physiologic  Therapeutics, 

page  17. 
FRENKEL.     Tabetic  Ataxia.     Illustrated.  $3.00 

GOULD.     Borderland    Studies.     Miscellaneous    Addresses    and 

Essays.     12mo.  $2.00 


MEDICAL  BOOKS.  19 

GOULD.  Biographic  Clinics.  The  Origin  of  the  Ill-Health  of 
DeQuincy,  Carlyle,  Darwin,  Huxley,  and  Browning.  JtLst 
Ready.  $1.00 

GREENE.     Medical    Examination    for    Life    Insurance.     Illus. 
With  colored  and  other  Engravings.     2d  Edition.       In  Press. 
HAIG.     Causation  of  Disease  by  Uric  Acid.     The  Pathology  of 
High  Arterial  Tension,  Headache,  Epilepsy,  Gout,  Rheuma- 
tism, Diabetes,  Bright's  Disease,  etc.     5th  Edition.         S3. 00 
HENRY.     A  Practical  Treatise  on  Anemia.  Half  Cloth,  .50 

NEW  SYDENHAM  SOCIETY'S  PUBLICATIONS.  Cu-culars 
upon  application.  Per  Annum,  §8.00 

OSGOOD.     The  Winter  and  Its  Dangers.  .40 

PACKARD.     Sea  Air  and  Sea  Bathing.  .40 

RICHARDSON.     Long  Life  and  How  to  Reach  It.  .40 

SCHEUBE.  Diseases  of  Warm  Countries.  Illustrated.  Just 
Ready.  S8.00 

TISSIER.     Pneumotherapy,    Aerotherapy,  Inhalation  Methods. 

See  Cohen,    Physiologic  Therapeutics,  page  17. 
TURNBULL.     Artificial  Anesthesia.     4th  Ed.     lUua.  $2.50 

WEBER  AND  HINSDALE.     Climatology  and  Health  Resorts. 
Including  Mineral  Springs.     2  vols.     Illustrated  with  Colored 
Maps.     See  Cohen,  Physiologic  Therapeutics,  page  17. 
WILSON.     The  Simmier  and  Its  Diseases.  .40 

WINTERNITZ.  Hydrotherapy,  Thermotherapy,  Phototherapy, 
Mineral  Waters,  Baths,  etc.  Illustrated.  See  Cohen,  Physio- 
logic Therapeutics,  page  17. 

NERVOUS  DISEASES. 

DERCUM.  Rest,  Suggestion,  Mental  Therapeutics.  See  Cohen, 
Physiologic  Therapeutics,  page  17. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central 
Nervous  System.  With  271  original  colored  and  other  Illus- 
trations. Cloth,  S6.00;  Sheep,  $7.00 

GOWERS.     Syphilis  and  the  Nervous  System.  $1.00 

GOWERS.     Manual   of   Diseases   of   the   Nervous   System.     A 
Complete  Text-Book.     Revised,  Enlarged,  and  in  many  parts 
Rewritten.     With  many  new  Illustrations.     Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.     3d  Edition, 
Enlarged.     •  Cloth,  $4.00 ;  Sheep,  S5.00 

Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves ;  General  and 
Functional  Disease.     2d  Ed.  Cloth,  $4.00;  Sheep,  $5.00 

GOWERS.  Epilepsy  and  Other  Chronic  Convulsive  Diseases. 
2d  Edition.  $3.00 

HORSLEY.  The  Brain  and  Spinal  Cord,  the  Structure  and 
Functions  of.     Numerous  Illustrations.  $2.50 

ORMEROD.  Diseases  of  the  Nervous  System.  66  Wood  En- 
gravings. $1.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases.  Illus- 
trated. $1.25 

PRESTON.  Hysteria  and  Certain  Allied  Conditions.  Their 
Nature  and  Treatment.     Illustrated.  $2.00 

WOOD.     Brain  Work  and  Overwork.  .40 


20  SUBJECT  CATALOGUE. 

NURSING  (see  also  Massage). 

Special  Catalogue  of  Books  for  Nurses  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Ucin^  a  Brief  Consideration  of  Asepsia,  Anti- 
sepsis, Disinfection,  Bacteriology,  Immunity,  Heating  and 
Ventilation,  and  Kindred  Subjects  for  the  Use  of  Nurses  and 
Other  Intelligent  Women.  $1.25 

CUFF.     Lectures  to  Nurses  on  Medicine.     3d  Edition.  SI. 25 

DAVIS.  Bandaging.  Its  Principles  and  Practice.  163  Original 
Illustrations.  $1.50 

DOMVILLE.  Manual  for  Nurses  and  Others  Engaged  in  At- 
tending the  Sick.  9th  Edition.  With  Recipes  for  Sick-room 
Cookerv,  etc.  In  PresB. 

FULLERTON.     Obstetric  Nursing.     5th  Ed.     41  Illus.         $1.00 

FULLERTON.     Surgical  Nursing.     3d  Ed.     69  Illus.  $1.00 

GROFF.  Materia  Medica  for  Nurses.  With  Questions  for  Self- 
Examination.  2d  Edition,  Revised  and  Improved.  Just 
Ready.  $1.25 

HADLEY.  General,  Medical,  and  Surgical  Nursing.  A  very 
Complete  Manual,  Including  .Sick-room  Cookery.  $1.25 

HUMPHREY.  A  Manual  for  Nurses.  Including  General 
Anatomy  and  Physiology,  Management  of  the  Sick-room,  etc. 
24th  Edition.     79  Illustrations.  $1.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feedinc  of  Infants  and  Children,  and  the  Domes- 
tic Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Ma-ssage,  etc.     6th  Edition.     25  Illustrations.  $1.00 

TEMPERATURE  AND  CLINICAL  CHARTS.     See  page  25. 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Enlarged. 
112  Illustrations.  $1.00 

OBSTETRICS. 

CAZEAUX  AND  TARNIER.  Midwifery.  With  Appendix  by 
Mund6.  The  Theory  and  Practice  of  Obstetrics,  including  the 
Diseases  of  Pregnancy  and  Parturition,  Obstetrical  Operations, 
etc.  8th  Edition.  Illustrated  by  colored  and  other  full-page 
Plates,  and  numerous  W'ood  Engravings. 

Cloth,  S4.50 ;  Full  Leather.  $5.50 

EDGAR.  Text-Book  of  Obstetrics.  By  J.  Clifton  Edgar. 
M.D.,  Professor  of  Obstetrics,  Medical  Department  of  Cornell 
University,  New  York  City.     1221  Illustrations. 

Nearly  Ready. 

FULLERTON.     Obstetric  Nursing.     5th  Ed.     Illus.  $1.00 

LANDIS.  Compend  of  Obstetrics.  7th  Edition,  Revised  by 
Wm.  H.  Wells,  m.d.,  Demonstrator  of  Clinical  Obstetrics, 
Jefferson  Medical  College.     52  Illustrations. 

.80;  Interleaved.  $1.00 

WINCKEL.  Text-Book  of  Obstetrics,  Including  the  Pathology 
and  Therapeutics  of  the  Puerperal  State.     Illustrated.      $5.00 

PATHOLOGY. 

BLACK.     Micro-Organisms.     The  Formation  of  Poisons.         .75 

BLACKBURN.     Autopsies.     A  Manual  of  Autopsies  Designed 

for  the  Use  of  Hospitals  for  the  Insane  and  other  Public  Instij 

tutions.     Ten  full-page  Plates  and  other  Illustrations.     $1.25 


MEDICAL  BOOKS.  21 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Tech- 
nic  of  Post-Mortems,  Methods  of  Pathologic  Research,  etc. 
330  Illustrations,  7  Colored  Plates.     3d  Edition.  S3.50 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  the 
Examination  of  the  Blood.  Six  Colored  Plates  and  48  Illus- 
trations. Cloth,  So.OO ;  Sheep,  S6.00 

LAZARUS-BARLOW.  Pathological  Anatomy.  With  7  Colored 
Plates  and  171  other  Illustrations.  S6.50 

MacLEOD.  The  Pathology  of  the  Skin.  Colored  and  other 
Illustrations.     Just  Ready.  So.OO 

ROBERTS.     Gynecological  Pathology.     Illustrated.  S6.00 

THAYER.     Compend  of  General  Pathology.     Illustrated. 

.80;  Interleaved,  Sl.OO 

THAYER.     Compend  of  Special  Pathology.     Illustrated. 

.80;  Interleaved,  Sl.OO 

VIRCHOW.     Post-Mortem  Examinations.     3d  Edition.  .75 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  With  121 
Illustrations.  $1.50 

PHARMACY. 

Special  Catalogue  of  Books  on  Pharmacy  sent  free  upon  application. 

COBLENTZ.  Manual  of  Pharmacy.  A  Complete  Text-Book  by 
the  Professor  in  the  New  York  College  of  Pharmacy..  2d  Ed., 
Revised  and  Enlarged.     437  Illus.     Cloth,  S3. 50 ;  Sheep,  S4.50 

COBLENTZ.     Volumetric  Analysis.      Illustrated.  SI. 25 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Jlost  Eminent  Physicians  and  Surgeons — Eng- 
lish, French,  and  American.  A  Compendious  History  of  the 
Materia  Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Es- 
tablished Preparations,  an  Index  of  Diseases  and  their  Reme- 
dies.    7th  Edition.  S2.00 

BEASLEY.  Druggists'  General  Receipt  Book.  Comprising  a 
Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Pro- 
prietary Medicines,  Druggists'  Nostrums,  etc. ;  Perfvunery  and 
Cosmetics,  Beverages,  Dietetic  Articles  and  Condiments,  Trade 
Chemicals,  Scientific  Processes,  and  many  Useful  Tables. 
10th  Edition.  S2.00 

BEASLEY.  Pharmaceutical  Formulary.  A  Synopsis  of  the 
British,  French,  German,  and  United  States  Pharmacopoeias. 
Compri-sing  Standard  and  Approved  Formula  for  the  Prepara- 
tions and  Compounds  Employed  in  Medicine.    12th  Ed.  S2.00 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated.  In  Press. 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine.  3d 
Edition.     With  elaborate  Vocabularies.  SI. 75 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the 
Vegetable  and  Animal  Drugs.  Comprising  the  Botanical  and 
Physical  Characteristics,  Source,  Constituents,  and  Pharma- 
copeial  Preparations,  Insects  Injurious  to  Drugs,  and  Phar- 
macal  Botany.  With  sections  on  Histology  and  Microtech- 
nique, by  W.  C.  Stevens.     374  Illustrations.    Second  Edition. 

Cloth,  S4.50 


22  SUBJECT  CATALOGUE. 


SCOVILLE.  The  Art  of  Compounding.  Second  Edition,  Re- 
vised and  Enlarged.  Cloth,  $2.50 

STEWART.  Compend  of  Pharmacy.  Based  upon  "Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  m 
Accordance  with  the  U.  S.  Pharmacopoeia,  1890.  Complete 
Tables  of  .Metric  and  English  Weights  and  Measures. 

.80;  Interleaved,  Sl.OO 

TAVERA.     Medicinal  Plants  of  the  Philippines.  $2.00 

UNITED  STATES  PHARMACOP(EIA.  7th  Decennial  Revision. 
Cloth,  S-'.50  (pi)stp:u<l,  §2.77);  Sheep,  $3.00  (postpaid,  $3.27); 
Interleaved,  S-1.00  (prist  imid,  $4.50);  Printed  on  one  aide  of 
page  only,  unbound,  $3. .50  (postpaid,  $3.90). 
Select  Tables  from  the  U.  S.  P.  Being  Nine  of  the  Most  Impor- 
tant and  Useful  Tables,  Printed  on  Separate  Sheets.         .25 

POTTER.  Handbook  of  Materia  Medica,  Pharmacy,  and  Thera- 
peutics.    600  Prescriptions.     9th  Edition. 

Cloth,  $5.00;  Sheep,  $6.00 

PHYSIOLOGY. 

BIRCH.     Practical   Physiology.     An    Elementary   Class   Book. 

62  Illustrations.  $1.75 

BRUBAKER.     Compend  of  Physiology.     11th  Edition,  Revised 

and  Enlarged.     Illustrated.  .80;  Interleaved,  $1.00 

JONES.     Outlines  of  Physiology.     96  Illustrations.  $1.50 

KIRKES.  Handbook  of  Physiology.  17th  Authorized  Edition. 
Revised,  Rearranged,  and  Enlarged.  By  Prof.  W.  D.  Halli- 
burton, of  Ivings  College,  London.  681  Illustrations,  some  of 
which  are  in  colors.  Cloth.  S3.00 ;  Leather,  $3.75 

LANDOIS.  A  Text-Book  of  Human  Physiology.  Including 
Histology  and  Microscopical  Anatomy,  with  Special  Reference 
to  the  Requirements  of  Practical  Medicine.  5th  A.rnerican, 
translated  from  the  last  German  Edition,  with  Additions  by 
Wm.  Stirling,  m.d.,  d.sc.  845  Illus.,  many  of  which  are 
printed  in  colors.  In  Press. 

STARLING.    Elements  of  Human  Physiology.     100  Illus.    $1.00 

STIRLING.  Outlines  of  Practical  Physiology.  Including  Chem- 
ical and  Experimental  Physiology,  with  Special  Reference  to 
Practical  Medicine.     3d  Edition.     289  Illustrations.        $2.00 

TYSON.     Cell  Doctrine.     Its  History  and  Present  State.     $1.50 

PRACTICE. 

BEALE.  On  Shght  Ailments  :  their  Nature  and  Treatment.  2d 
Edition,  Enlarged  and  Illustrated.  $1.25 

COHEN.  Physiologic  Therapeutics.  The  Treatment  of  Disease 
by  Methods  other  than  Drug-giving.     See  page  17. 

FAGGE.  Practice  of  Medicine.  4th  Edition,  by  P.  H.  Pte- 
Smith,  m.d.     2  volumes.  Vol.  I,  $6.00;  Vol.  II,  $6.00 

FOWLER.  Dictionary  of  Practical  Medicine.  By  various 
writers.     An  Encyclopjedia  of  Medicine. 

Cloth,  $3.00;  Half  Morocco,  $4.00 


MEDICAL  BOOKS.  23 


GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  A  Concise  Reference  Handbook,  with  particular 
Reference  to  Diagnosis  and  Treatment.  Edited  by  Dks. 
Gould  and  Pyle,  Assisted  by  72  Special  Contributors.  Illus- 
trated, one  volume.  Large  Square  Octavo,  Uniform  with 
"Gould's  Illustrated  Dictionary." 

Sheep  or  Half  Mor.,  SIO.OO;  with  Thumb  Index,  Sll.OO 
Half  Russia,  Thumb  Index,  S12.00 
>KS°°  Complete  descriptive  circular  free  upon  application. 
GOULD  AND  PYLE'S  Pocket  Cyclopedia  of  Medicine  and  Sur- 
gery.    Based  upon  the  above  and  Uniform  ■nith   "Gould's 
Pocket  Dictionary."     Full  Limp  Leather,  GUt  Edges,  Round 
Corners,  SI. 00;  with  Thumb  Index,  SI. 25. 
HUGHES.     Compend  of  the  Practice  of  Medicine.     6th  Edition, 
Revised  and  Enlarged. 

Part  I.     Continued,  Eruptive,  and  Periodical  Fevers,  Diseases 
of  the  Stomach,  Intestines,  Peritoneum,  Biliary  Passages, 
Liver,  Kidneys,  etc.,  and  General  Diseases,  etc. 
Part  II.     Diseases  of  the  Respiratory  System,   Circulatory 
System,  and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  .80;  Interleaved,  SI. 00 
Physician's  Edition.     In  one  volimie,  including  the  above  two 
parts,  a  Section  on  Skin  Diseases,  and  an  Index.     6th  Re- 
vised Edition.     625  pp.     Full  Morocco,  GUt  Edge,  S2.25 
TAYLOR.     Practice  of  Medicine.     6th  Edition.  S4.00 

TYSON.  The  Practice  of  Medicine.  By  James  Tyson,  m.d.. 
Professor  of  Medicine  in  the  University  of  Pennsylvania.  A 
Complete  Systematic  Text-book,  with  Special  Reference  to 
Diagnosis  and  Treatment.  2d  Edition,  Enlarged  and  Revised. 
Colored  Plates  and  125  other  Illustrations.     1222  pages. 

Cloth,  S5.50;  Leather,  S6.50 

STOMACH.     INTESTINES. 

FENWICK.     Cancer  of  the  Stomach.     JuJit  Ready.  S3.00 

HEMMETER.  Diseases  of  the  Stomach.  Their  Special  Pathol- 
ogy, Diagnosis,  and  Treatment.  _  With  Sections  on  Anatomy, 
Analysis  of  Stomach  Contents,  Dietetics.  Surgery  of  the  Stom- 
ach, etc.  3d  Edition,  Revised.  With  15  Plates  and  41  other 
Illustrations,  a  number  of  which  are  in  colors. 

Cloth,  S6.00;  Sheep,  $7.00 
HEMMETER.  Diseases  of  the  Intestines.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy 
and  Physiology,  Microscopic  and  Chemic  Examination  of  In- 
testinal Contents,  Secretions,  Feces  and  Urine,  Intestinal 
Bacteria  and  Parasites,  Surgery  of  the  Intestines,  Dietetics, 
Diseases  of  the  Rectum,  etc.  With  Full-page  Colored  Plates 
and  many  other  Original  Illustrations.  2  volumes.  Octavo. 
Price  of  each  volume,  Cloth,  S5.00 ;  Sheep,  S6.00 

SKIN. 

BULKLEY.     The  Skin  in  Health  and  Disease.    Illustrated.     .40 
CROCKER.     Diseases  of  the  Skin.     Their  Description,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the 
Skin  Eruptions  of  Children.     3d  Edition,  Thoroughlv  Revised. 
With  New  lUus.     Just  Ready.  Cloth,  S5.00 ;  Sheep,  S6.00 

MacLEOD.  The  Pathology  of  the  Skin.  Colored  and  other 
Illustrations.     Ju^t  Ready.  S5.00 


24  SUBJECT  CATALOGUE. 

SCHAMBERG.  Diseases  of  the  Skin.  3d  Edition,  Revised  and 
Enlarged.  106  Illustrations.  Being  No.  16  ?  Quiz-Compend? 
Series.     Just  Ready.  Cloth,  .80;  Interleaved,  $1.00 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diagnosis  and  Treatment,  with  Special  Reference  to  Differ- 
ential Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With 
Formulae  and  60  Illustrations,  some  of  which  are  printed  in 
colors.  $2.75 

SURGERY  AND  SURGICAL  DISEASES 

(see  also  Urinary  Organs). 

BERRY.     Diseases  of  the  Thyroid  Gland.     Illustrated.       $4.00 

BUTLIN.  Operative  Surgery  of  Malignant  Disease.  2d  Edi- 
tion.    Illustrated.     Octavo.  $4.50 

CASPER  AND  RICHTER.     Functional  Kidney  Diagnosis.  $1.50 

DAVIS.  Bandaging.  Its  Principles  and  Practice.  163  Original 
Illustrations.  $1.50 

DEAVER.  Siirgical  Anatomy.  A  Treatise  on  Human  Anatomy 
in  its  Application  to  Medicine  and  Surgery.  With  about  500 
very  handsome  full-page  Illustrations  Engraved  from  Original 
Drawings  made  by  special  Artists  from  Dissections  prepared 
for  the  purpose.  Three  volumes.  Royal  Square  Octavo. 
By  Subscription  only.     Now  Ready. 

Half  Morocco  or  Sheep,  $24.00 ;  Half  Russia,  $27.00 

DEAVER.  Appendicitis  :  its  Symptoms,  Diagnosis,  Pathology, 
Treatment,  and  Complications.  Elaborately  Illustrated  with 
Colored  Plates  and  other  lUus.     3d  Edition.  Preparing. 

DOUGLAS.  Siirgical  Diseases  of  the  Abdomen.  Illustrated 
by  20  Full-page  Plates.     Ju^t  Ready. 

Cloth,  $7.00;  Sheep,  $8.00 

DULLES.  What  to  do  First  in  Accidents  and  Poisoning.  5th 
Edition.     New  Illustrations.  $1.00 

FULLERTON.     Surgical  Nursing.     3d  Ed.     69  Ulus.  $1.00 

HAMILTON.     Lectures  on  Tumors.     3d  Edition.  $1.25 

HEATH.  Minor  Surgery  and  Bandaging.  12th  Edition,  Re- 
vised and  Enlarged.  195  Illus.,  Formulse,  Diet  List,  etc.  $1.50 

HEATH.     Clinical  Lectures  on  Surgical  Subjects.     Second  Series. 

$2.00 

HORWITZ.  Compend  of  Surgery  and  Bandaging.  Including 
Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical 
Diseases,  etc.,  with  Differential  Diagnosis  and  Treatment.  5th 
Edition,  very  much  Enlarged  and  Rearranged.  167  Ulus.,  98 
Formula.  Cloth,  .80;  Interleaved,  $1.00 

JACOBSON.  Operations  of  Surgery.  4th  Ed.,  Enlarged.  550 
Illus.     Two  volumes.  Cloth,  $10.00;  Leather,  $12.00 

KEAY.     Medical  Treatment  of  Gail-Stones.  $1.25 

KEHR.  Gall-stone  Disease.  Translated  by  William  Wotktns 
Setmoub,  m.d.  $2.50 

MAKINS.  Surgical  Experiences  in  South  Africa.  1899-1900. 
lUustrated.  $4.00 

MAYLARD.  Sturgery  of  the  Alimentary  Canal.  97  Illustrations. 
2d  Edition,  Revised.  $3.00 


MEDICAL  BOOKS.  25 

MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by 
John  B.  Hamtlton,  m.d.,  ll.d.,  Professor  of  the  Principles  of 
Surgery  and  Clinical  Siirgery,  Rush  Medical  College,  Chicago. 
623  Illustrations,  many  of  which  are  printed  in  colors. 

Cloth,  S6.00 ;  Leather,  S7.00 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description 
of  all  the  Principal  Operations.  224  Illustrations.  6th  Edi- 
tion.    2  volumes.  Cloth,  SIO.OO 

VOSWINEIEL.  Surgical  Nursmg.  Second  Edition,  Revised  and 
Enlarged.     Ill  Illustrations.  $1.00 

WALSHAM.  Manual  of  Practical  Sm-gery.  7th  Ed.,  Revised 
and  Enlarged.     483  Engravings.     950  pages.  $3.50 

TEMPERATURE  CHARTS,  ETC. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Tempera- 
ture, Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex,  Occu- 
pation, Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  50  cts.  Price  to 
Hospitals,  500  copies,  $4.00;  1000  copies,  $7.50. 

KEEN'S  Clinical  Charts.  Seven  Outline  Drawings  of  the  Body, 
on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Each  Drawing  may  be  had  separately, 
twenty-five  to  pad,  25  cents. 


THROAT  AND  NOSE  (see  also  Ear). 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.  Diseases  of  the  Nose  and  Throat.  2d  Edition,  Enlarged. 
Two  Colored  Plates  and  80  Illustrations.  $2.75 

HOLLOPETER.     Hay  Fever.     Its  Successful  Treatment.    $1.00 

EINIGHT.  Diseases  of  the  Throat.  A  Manual  for  Students. 
Illustrated.  Nearly  Ready. 

KYLE  (J.  J.).  Diseases  of  the  Ear,  Nose,  and  Throat.  A  Com- 
pend  for  Students.     Illustrated.  .80;  Interleaved,  $1.00 

McBRIDE.  Diseases  of  the  Throat,  Nose,  and  Ear.  With  Col- 
ored Illustrations  from  Original  Drawings.     3d  Ed.         $7.00 

POTTER.  Speech  and  its  Defects.  Considered  Physiologically, 
Pathologically,  and  Remedially.  $1.00 

URINE  AND  URINARY  ORGANS. 

ACTON.  The  Functions  and  Disorders  of  the  Reproductive 
Organs  in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life, 
Considered  in  their  Physiological,  Social,  and  Moral  Relations. 
8th  Edition.  $1.75 

CASPER  AND  RICHTER,    Functional  Kidney  Diagnosis.    $1.50 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Micro- 
scopical, for  Laboratory  Use.  Illustrated  and  Interleaved. 
6th  Edition.  $1.00 

KLEEN.     Diabetes  and  Glycosuria.  $2.50 


26  SUBJECT  CATALOGUE. 


MEMMIRGER.  Diagnosis  by  the  Urine.  2d  Edition.  24  IlluB- 
trations.  $1.00 

MORRIS.  Renal  Surgery,  with  Special  Reference  to  Stone  in  the 
Kiiiney  and  Ureter  and  to  the  Surgical  Treatment  of  Calculous 
Anuria.     Illustrated.  $2.00 

MOULLIN.  Enlargement  of  the  Prostate.  Its  Treatment  and 
Ra<liral  Cure.     2d  Edition.     Illu.strated.  $1.75 

MOULLIN.  Inflammation  of  the  Bladder  and  Urinary  Fever. 
Octavo.  $1.50 

SCOTT.  The  Urine.  Its  Clinical  and  Microscopical  Examina- 
tion.    41  LithoRraphic  Plates  and  other  Illustrations.    Quarto. 

Cloth,  $5.00 

TYSON.  Guide  to  Examination  of  the  Urine.  For  the  Use  of 
^Phy.sicians  and  Students.  With  Colored  Plate  and  Numerous 
Illustrations  engraved  on  wood.  10th  Edition,  Revised,  En- 
larged, and  partly  Rewritten.  With  New  Illustrations.  JuM 
Rendu.  $1.50 

VAN  NUYS.     Chemical  Analysis  of  Urine.     39  Ulus.  $1.00 

VENEREAL  DISEASES. 

GOWERS.     Syphilis  and  the  Nervous  System.  $1.00 

STURGIS  AND  CABOT.     Student's  Manual  of  Venereal  Diseases. 

7th  Revised  and  Enlarged  Edition.      12mo.  $1.25 

VETERINARY. 

BALLOU.  Veterinary  Anatomy  and  Physiology.  29  Graphic 
Illustrations.  .80;  Interleaved,  $1.00 


JACOBSON.  The  Operations  of  Surgery.  By 
W.  H.  A.  Jacobson,  F.R.C.S.,  Surgeon  to 
Guy's  Hospital ;  Consulting  Surgeon  Royal 
Hospital  for  Children  and  Women  ;  and  F. 
J.  Steward,  f.r.c.s.,  Assistant  Surgeon 
Guy's  Hospital.  Fourth  Edition — Revised, 
Enlarged,  and  Improved.  550  Illustrations. 
Two  Volumes,  Octavo,  1524  pages. 

Cloth,  SIO.OO;  Sheep,  S12.00 

"  The  important  anatomical  points  are  clearly  set  forth,  the 
conditions  indicating  or  contraindicating  operative  interference 
are  given,  the  details  of  the  operations  themselves  are  brought 
forward  prominently,  and  frequently  the  after-treatment  is 
considered.  Herein  is  one  of  the  strong  points  of  the  book." — 
New  York  Medical  Journal. 


' '  We  know  of  no  series  of  books  issued  by  any  house  that  so 
fully  meets  our  approval  as  these  ?  Quiz-Compends7.  They  are 
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text-books  that  could  be  found  for  either  student  or  practitioner." 
— Southern  Clinic. 

BLAKISTON'S  ?QUIZ-COMPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 
Price  of  each,  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1.00 

These  Compends  are  based  on  the  most  popular  text-books 
and  the  lectvues  of  prominent  professors,  and  are  kept  constantly 
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they  could  be  used  to  advantage.  Can  be  used  by  students  of 
any  coUege.  They  contain  information  nowhere  else  collected  in 
such  a  condensed,  practical  shape. 

No.  I.  POTTER.  HUMAN  ANATOMY.  Sixth  Edition.  117 
Illustrations  and  16  Plates  of  Nerves  and  Arteries. 

No.  2.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  Sixth 
Edition,  Enlarged  and  Improved. 

No.  3.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  H.  Sixth 
Edition,  Revised  and  Improved. 

No.  4.  BRUBAKER.     PHYSIOLOGY.     Eleventh  Edition.    Illus. 

No.  5.  LANDIS.     OBSTETRICS.     Seventh    Edition.     52    Illus. 

No.  6.  POTTER.  MATERIA  MEDICA,  THERAPEUTICS,  AND 
PRESCRIPTION  WRITING.     Sixth  Revised  Edition. 

No.  7.  WELLS.     GYNECOLOGY.     Thurd  Edition.     140  Illus. 

No.  8.  GOULD  AND  PYLE.  DISEASES  OF  THE  EYE.  Second 
Edition.     Refraction,  Treatment,  Surgery,  etc.     109  Illus. 

No.  9.  HORWITZ.  SURGERY.  Including  Minor  Siirgery, 
Bandaging,  Surgical  Diseases,  Differential  Diagnosis  and 
Treatment.  Fifth  Edition.  With  98  Formulse  and  71  Illus- 
trations. 

No.  10.  LEFFMANN.  MEDICAL  CHEMISTRY.  Fourth  Edi- 
tion. Including  Urinalysis,  Animal  Chemistry,  Chemistry 
of  Milk,  Blood,  Tissues,  the  Secretions,  etc. 

No.  II.  STEWART.  PHARMACY.  Fifth  Edition.  Based  upon 
Prof.  Remington's  Text-Book  of  Pharmacy. 

No.  12.  BALLOU.  VETERINARY  ANATOMY  AND  PHYSI- 
OLOGY.    29  graphic  Illustrations. 

No.  13.  WARREN.  DENTAL  PATHOLOGY  AND  DENTAL 
MEDICINE.     Third  Edition,  Illustrated. 

No.  14.  HATFIELD.     DISEASES  OF  CHILDREN.     3d  Edition. 

No.  IS.  THAYER.     GENERAL  PATHOLOGY.     78  Illus. 

No.  16.  SCHAMBERG.  DISEASES  OF  THE  SKIN.  Third 
Edition,  Revised  and  Enlarged.     106  Illustrations. 

No.  17.  GUSHING.     HISTOLOGY.     Illustrated.  In  Press. 

No.  18.  THAYER.     SPECIAL  PATHOLOGY.     34  Illustrations. 

No.  19.  KYLE.  DISEASES  OF  THE  EAR,  NOSE,  AND 
THROAT.     Illustrated.  In  Press. 

27 


DA  COSTA 

Clinical  Hematology 


A  Practical  Guide  to  the  Examination  of  the  Blood  by 
Clinical  Methods.  With  Reference  to  the  Diagnosis  of 
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*^*  A  new,  thorough,  systematic,  and  comprehensive 
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diseases  of  the  blood  itself  and  general  diseases.  The 
author's  aim  has  been  to  cover  not  alone  the  field  of  original 
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physician  and  the  general  practitioner.  It  will  be  found 
wanting  in  none  of  these  respects. 

OERTEL 


Medical  Microscopy 

JUST  READY 

A  GUIDE  TO  DIAGNOSIS,  ELEMEN- 
TARY LABORATORY  METHODS, 
AND    MICROSCOPIC    TECHNtC 


By  T.  E.  Oertel,  M.D., 

Professor  of  Pathology  and  Clinical  Microscopy,  Medical  Depart- 
ment, University  of  Georgia. 

WITH  131  ILLUSTRATIONS,    izmo.    Cloth,  $2.00 
28 


Thg  Pocket  CyclopediaL  of 
Medicine   and   Surgery 

Fall  Limp  Leather,  Round  Corners,  Gilt  Edges,  $1.00 
With  Thumb  Index,  $1.25 

Uniform  -with  "  Gould's  Pocket  Dictionary  " 


A  concise  practical  volume  of  nearly  600 
pages,  containing  a  vast  amount  of  infor- 
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with  Formulas  and  Prescriptions,  Emer- 
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Nursing,  Surgical  Procedures,  Dose  List 
in  both  English  and  Metric  Systems,  etc. 

By  Drs.  Gould  and  Pyle 

Based  upon  their  large  "Cyclopedia  of 
Medicine  and  Surgery."      v?t       «jt       »jt 


*^*  This  is  a  new  book  which  will  prove  of  the  greatest 
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It  is  Multum  in  Parvo.  Sample  Pages  Free. 
29 


A  NEW  EDITION 


Crocker  on  the  Skin 


The  Diseases  of  the  Skin.  Their  Description,  Pathology, 
Diagnosis,  and  Treatment,  with  Special  Reference  to  the 
Skin  Eruptions  of  Children.  By  H.  Radcufke  Crocker, 
M.D.,  Physician  to  the  Department  of  Skin  Diseases,  Uni- 
versity College  Hospital,  London.     With  new  Illustrations. 

Third  Edition,   Rewritten  and   Enlarged 

OCTAVO.    JUST  READY;  CLOTH,  $5.00 

*^*  This  new  edition  will  easily  hold  the  high  position 
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logical  Societies,  and  a  recognized  authority  the  world  over. 


STURGiS— MANUAL  OF 
VENEREAL  DISEASES 


By  ¥.  R.  Sturgis,  m.d..  Sometime  Clinical  Professor  of 
Venereal  Diseases  in  the  Medical  Department  of  the  Uni- 
versity of  the  City  of  New  York.  Seventh  Edition,  Revised 
and  in  Part  Rewritten  by  the  Author  and  Foi.LEN  Cabot, 
M.D.,  Instructor  in  Genito-Urinary  and  Venereal  Diseases 
in  the  Cornell  University  Medical  College.  l2mo.  2l6 
pages.  Cloth,  Jl.25 

***  This  manual  was  originally  written  for  students' 
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the  general  physician,  together  with  the  most  approved 
remedies. 

80 


FOR  THE  DISSECTING  ROOM 

Holden's  Anatomy — Seventh  Edition 
320  Illustrations 

A  Manual  of  the  Dissections  of  the  Human  Body.  By  John 
Langton,  F.R.C.S.  Carefully  Revised  by  A.  Hewson,  M.D., 
Demonstrator  of  Anatomy.  Jefferson  Medical  College,  Phila- 
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Extremity.      435  pages.      153  Illustrations. 

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Vol.  II.  Abdomen,  Perineum,  Lower  Extremity,  Brain, 
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445  pages.      167  Illustrations. 

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IllustraLted 

A  Manual  of  Dissections  by  Alfred  W.  Hughes,  m.b., 
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I..     Upper  and  Lower  Extremity.     38  Plates,  1 16  other 
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II.      Abdomen.      Thorax.     4    Plates,    149    other   Illus- 
trations. Cloth,  $3.00 
III.      Head,    Neck,  and  Central   Nervous    System.       16 
Plates,  204  other  Illustrations.          Cloth,  $3.00 

Each  volume  sold  separately. 

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31 


EDGARS 

OBSTETRICS 

A    NEW   TEXT -BOOK 
I  22  I    Illustrations 


Edgar's  Obstetrics  excels  all 
other  works  on  this  subject 
in  completeness,  in  uni- 
formity and  consistency  in 
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and  clearness  in  handling 
details,  and  in  the  number 
and  usefulness  of  its  illus- 
trations. 

NEARLY  READY 


